. 


Types  of  normal  breast-  and  bottle-  fed  infants. 

1.  Baby  Y     14  months.     Bottle-fed  from  birth.     2.  B.  J.  S.,  11  months. 

Bottle-fed  after  4th  month.    3.  E.   S.,  6  months.     Breast-fed. 


A   PRACTICAL  TREATISE 

1L  o 


ON  ^ 


INFANT  FEEDING 

AND 

ALLIED  TOPICS! 

FOR     PHYSICIANS     AND     STUDENTS 


BY 

HARRY  LOWENBURG,  A.M.,  M.D. 

Assistant   Professor   of   Pediatrics,    Medico-Chirurgical    College  of   Philadelphia; 

Pediatrist  to  the  Mt.   Sinai  Hospital;   Pediatrist  to  the  Jewish  Hospital; 

Pediatrist  to  the  Jewish  Maternity  Hospital;  Consulting  Pediatrist 

to  the  Hebrew  Orphans'  Home;  Assistant  Pediatrist  to  the 

Medico-Chirurgical  Hospital  and  to  the  Philadelphia 

General     Hospital;     Formerly     Instructor    of 

Pediatrics,    Jefferson    Medical    College. 


Illustrated  with  64  Text  Engravings  and  30  Original  Full- 
page  Plates,   11  of  which  are  in  Colors. 


PHILADELPHIA 

F.  A.  DAVIS  COMPANY,   PUBLISHERS 

ENGLISH  DEPOT 
STANLEY  PHILLIPS,  LONDON 

1916 


2« 


VJS19-G 


COPYRIGHT,   1916 

BY 
F.  A.  DAVIS  COMPANY 

Copyright,  Great  Britain.      All  Rights  Reserved, 


Philadelphia,  Pa.,  U.  S.  A. 

Press  of  F.  A.  Davis  Company 

1914-16  Cherry  Street 


DEDICATION 


IN  REVERENT  AND  AFFECTIONATE  MEMORY 
OF  MY  MOTHER 

HENRIETTA   LOWENBURG 


PREFACE. 


THE  author's  purpose  in  publishing  a  work  upon  "Infant 
Feeding  and  Allied  Topics"  is  to  meet  the  many  requests 
received  from  his  students  and  from1  his  medical  colleagues 
who  have  honored  him  with!  their  confidence.  The  con- 
tents will  be  found  to  be  largely  clinical  and  practical,  and 
to  embody  the  author's  personal  experience  with  the  prob- 
lems presented.  Theorizing  and  the  presentation  of  a 
medley  of  views  of  different  authorities  have  been  studi- 
ously avoided.  Credit  has  not  always  been  given  for  views 
expressed  which  are  not  original,  although  the  attempt  has 
been  made  to  do  so  where  the  fact  stated  is  eminently  new 
and,  as  yet,  has  not  become  a  part  of  common  medical 
knowledge.  Quotations  and  references  have  been  avoided 
as  much  as  possible,  as  they  are  time-consuming  and  gen- 
erally annoying,  distracting  the  mind  of  the  reader  from 
the  text.  In  not  a  few  instances  the  author  has  indulged 
in  the  repetition  of  certain  facts  and  statements.  This  has 
been  done  largely  for  the  sake  of  emphasis  and  to  insure 
the  individual  completeness  of  the  presentation  of  the  par- 
ticular topic  under  discussion,  and  also  to  avoid  references 
and  cross-references. 

A  serious  attempt  has  been  made  to  emphasize  the  im- 
portance of  breast  feeding  and  the  digestive  problems  which 
present  themselves  in  this  class  of  patients. 

The  influence  of  the  German  school  of  pediatrics  has 
been  presented  in  a  conservative  way,  and  simply  includes 

(v) 


vi  PREFACE. 

the  author's  personal  experience  with  the  ideas  promul- 
gated by  this  brilliant  coterie  of  workers. 

Adherence  to  the  percentage  idea,  in  its  broader  sense, 
has  been  maintained,  as  furnishing  a  valuable  method  of 
thinking,  and  not  as  a  "conditio,  sine  qua  non,"  the  idea 
being  that  individualization  is  the  basic  principle  of  suc- 
cessful infant  feeding.  The  advantages  and  disadvantages 
of  the  caloric  system  have  been  discussed. 

As  a  means  of  adapting  milk  to  the  individual  require- 
ments the  top-milk  methods  and  the  miilk-andLcream 
mixture  methods  have  been  abandoned  as  being  too  cumber- 
some, and  often  incomprehensible  to  both  the  physician  and 
to  the  caretaker.  The  dilution  of  whole  or  of  skimmed  milk 
is  advocated  as  simple  and  efficient.  Where  their  use  has 
given  good  results  the  author  recommends  a  few  pro- 
prietaries, not  as  substitutes  for,  but  as  adjuvants  to  cows* 
milk. 

The  author's  thanks  are  due,  and  are  hereby  gratefully 
acknowledged,  to  Prof.  John  B.  Deaver,  who  has  written 
the  article  upon  "Surgical  Treatment  of  Infantile  Pyloric 
Obstruction." 

To  his  sister,  Miss  Sara  Lowenburg,  the  author  wishes 
to  express  his  appreciation  for  her  assistance  while  the 
work  was  passing  through  the  press.  To  Robert  A. 
Schless,  senior  student  at  Jefferson  Medical  College,  and 
to  Malvin  H.  Reinheimer,  Esq.,  for  their  unselfish  and 
enthusiastic  assistance  in  reading  proof,  and  preparing  the 
index,  the  author  is  likewise  gratefully  indebted.  The 
majority  of  the  Rontgenograms  were  made  by  Dr.  Geo. 
Rosenbaum,  of  Mt.  Sinai  Hospital,  Philadelphia. 

HARRY  LOWENBURG. 
1927  N.  BROAD  ST., 
PHILADELPHIA,  PA. 


CONTENTS. 


CHAPTER  I. 

PAGE 

BREAST  FEEDING   1 

CHAPTER  II. 
ARTIFICIAL  FEEDING  49 

CHAPTER  III. 
ARTIFICIAL  FEEDING   (continued)    118 

CHAPTER  IV. 
INFANTILE  ATROPHY   ISO 

CHAPTER  V. 
RICKETS  185 

CHAPTER  VI. 
SCURVY 222 

CHAPTER  VII. 
VOMITING    232 

CHAPTER  VIII. 
CONSTIPATION    247 

CHAPTER  IX. 

DIARRHEA    260 

(vii) 


viii  CONTENTS. 

CHAPTER  X. 

PAGE 

SPASMOPHILIA  276 

CHAPTER  XI. 
EXUDATIVE  DIATHESIS   297 

CHAPTER  XII. 
PYLORIC  OBSTRUCTION  313 

CHAPTER  XIII. 
SPECIAL  TOPICS  350 

IXDEX  .  375 


LIST  OF  ILLUSTRATIONS. 


FIG.  PAGE 

1  The  mammary  gland    (Gray.)    3 

2  Artificial  nipple  or  nipple-shield  7 

3  Breast-pump.     (Physician's  Supply  Co.,  of  Phila.)   9 

4  Massaging  breast   11 

5  Abscesses  not  interfering  with  breast  feeding  12 

6  Microphotograph  of  colostrum  13 

7  Microphotograph  of  human  and  of  cows'  milk  15 

8  Stripping  of  breast  for  sample  18 

9  Lactometer.     (Physician's  Supply  Co.,  of  Phila.)    19 

10  Creamometer  for  estimating  percentage  of  fat.     (Holt)    22 

11  Babcock's    centrifuge    tube    for    estimating    fat.      (Arthur    H. 

Thomas   Co.)    22 

12  Babcock's  pipette  for  estimating  fat   23 

13  Eschbach's   albuminometer   used   in   protein   test.      (Arthur   H. 

Thomas   Co.)    23 

14  Types  of  good  nursing  breasts   31 

15  How  to  hold  an  infant  while  at  the  breast  39 

16  Proper   can  used  in  milking  cows.      (Dairyman's   Supply   Co., 

Philadelphia,    Pa.)     64 

17  Freeman's  pasteurizer    92 

18  Apparatus  used  in  mixing  formula  95 

19  Nursing  bottle    96 

20  A  good  type  of  nipple  96 

21  Bottle-brush  (Physician's  Supply  Co.,  of  Phila.)    97 

22  Showing  correct  rapidity  of  flow  of  formula  through  nipple  . .  98 

23  Nursery  refrigerator.     (Courtesy  of  Gimbel  Bros.,  Phila.) 99 

24  Home  buttermilk  churner.     (Gimbel  Bros.,  Phila,  Pa.)    122 

25  Flour   ball 134 

26,  27  Essential  marasmus   156,  157 

28  Marasmus 158 

29  Frog  appearance  in  essential  marasmus    159 

30  Marasmus  complicated  by  edema   161 

31  Atrophy  or  marasmus  due  to  chronic  cerebrospinal  meningitis  .  167 

32  Square  outline  of  head  in  rickets   193 

33  Rachitic   kyphosis    197 

34  Rickets    198 

35  Rachitic    rosary    199 

(ix) 


x  LIST  OF  ILLUSTRATIONS. 

FIG.  PAGE 

36  Rachitic    scoliosis    201 

37  Tubercular  kyphosis   203 

38  Pot  belly  and  bow-legs   204 

39  Rickets.    Anterior  bowing  of  tibia  and  pot  belly  205 

40  Rickets.    Pot  belly  and  protruding  umbilicus   207 

41  Double  congenital   dislocation  of  hip    212 

42  Scurvy 227 

43  Same  child  after  recovery  from  scurvy  229 

44  Constipation  due  to  dilated  colon.     (Hirschsprung's  disease.)   . .  253 

45  Massage  balls.     (Physician's  Supply  Co.,  of  Phila.)    258 

46  Percussion   hammer    283 

47  Lingua  geographica    306 

48  Showing  pyloric  obstruction    313 

49  Weight  curve   in   a  case   of   complete   or  surgical  pyloric   ob- 

struction      317 

50  Effect  of  posterior  gastroenterostomy  on  weight  curve  318 

51  Visible  gastric  peristalsis   319 

52,   53   Weight   charts  of   two   cases   of   incomplete   non-surgical 

pyloric   obstruction    326 

54  Weighing  the  baby   328 

55  From  combined  weight  of  baby  and  towel  subtract  the  weight 

of  towel  to  obtain  result   329 

56  Apparatus  for  stomach  washing,  etc 351 

57,  58  Stomach  washing  354,  355 

59,  60  Colonic  irrigation  with  the  catheter  357,  358 

61  Giving  a  colonic  irrigation  or  a  high  enema  without  inserting 

the    catheter    359 

62  Nasal    feeding    362 

63  Hypodermoclysis    371 

64  Necrosis  and  ulceration  from  the  subcutaneous  injection  of  car- 

bonate of  soda  and  sodium  chlorid  solution  .  372 


LIST  OF  PLATES. 


PLATE  FACING    PAGE 

Types  of  normal  breast-  and  bottle-  fed  infants.  .Frontispiece 

I.     Meconium   (colored)    16 

II.     Normal  breast  stool    (colored)    28 

III.  Normal  stool  of    artificially  fed  baby  (colored)    32 

IV.  Stool  of  indigestion  in  the  breast-fed  (colored)   36 

V.     Stool  of  dyspepsia    (colored)    40 

VI.     Constipated,  greasy  stool  of  artificially  fed  infant,  due 

to  administration  of  too  much  fat  (colored)   64 

VII.     Hard,   constipated,  calcium-soap   stool   due  to  adminis- 
tration of  too  much  fat  (colored)    80 

VIII.     Hard,  dry,  whitish,  constipated,  crumbly  stool,  consist- 
ing of  undigested  protein,  occurring  in  a  bottle-fed 

baby  (colored)    104 

IX.     Stool    of    a    case    of    diarrhea    discolored    by    bismuth 

(colored)    128 

X.     Same    case    as    Plate    IX.      Diarrhea    more    advanced 

(colored)    144 

XL     Tubercular   kyphosis    200 

XII.     The  appearance  of  the  gums  in  a  case  of  infantile  scurvy 

(colored)    224 

XIII.  Showing  stomach-tube  in  situ  in  a  case  of  intense  gas- 

tric dilation 316 

XIV.  Practically  complete  obstruction   320 

XV.     Same  case  as  Plate  XIV.     One  hour  after  the  adminis- 
tration of  the  bismuth    320 

XVI.     Same  case  as  Plate  XIV.     Three  hours  later.     No  bis- 
muth has  left  the  stomach  320 

XVII.     Same  case  as  Plate  XIV.     Six  hours  later  320 

XVIII.     Same  case  as  Plate  XIV.    The  next  day,  about  nineteen 

hours  later  320 

XIX.     Comet-like   appearance   of   the  bismuth   shadow   at  the 

pylorus  in  cases  of  complete  obstruction   320 

XX.     Non-surgical  incomplete  pyloric  obstruction   336 

(xi) 


Xll 


LIST    OF    PLATES. 


PLATE  FACING   PAGE 

XXI.     Same  case  as  Plate  XX.    Two  hours  later  336 

XXII.    Same  case  as  Plate  XX.    Bismuth  still  in  stomach,  four 

hours  after  administration   336 

XXIII.  Same  case   as   Plate  XX.     Much   bismuth   still  in  the 

stomach,  but  also  seen  in  descending  colon  and 
sigmoid    336 

XXIV.  Same  case  as  Plate  XX.    Eighteen  hours  later 336 

XXV.    Case  of  incomplete  but  surgical  pyloric  obstruction 336 

XXVI.    Same  case  as   Plate  XXV.     Bismuth  in  stomach,  two 

hours  later 336 

XXVII.    Same  case  as  Plate  XXV.    Four  hours  later  336 

XXVIII.    Same  case  as  Plate  XXV.    Eight  hours  later  336 

XXIX.     Same  case  as  Plate  XXV.    Sixteen  hours  later  .  .  336 


CHAPTER  I. 
BREAST  FEEDING. 


MATERNAL  AND  MEDICAL  RESPONSIBILITY. 

PHYSICIANS  have  long  recognized  that  the  best  food  for 
an  infant  is  human  milk.  In  spite  of  this,  thousands' of 
children  continue  to  be  placed  upon  artificial  feeding,  some 
to  thrive,  some  to  live  and  to  suffer  from  nutritional  dis- 
eases, and  some  to  die.  The  responsibility  for  the  failure 
to  conserve  the  maternal  milk-supply,  while  dual,  rests  with 
greater  weight  upon  the  physician,  who,  while  realizing  the 
value  of  natural  and  the  dangers  and  uncertainties  of  arti- 
ficial feeding,  has  failed  to  become  fired  with  that  enthu- 
siasm which  the  subject  demands.  Consequently  many 
mothers  are  lacking  in  enthusiasm. 

It  must  be  stated,  first,  that  the  majority  of  women, 
providing  they  are  disease-free,  can  nurse  their  young. 
The  physician  should,  therefore,  from  the  day  that  his  pa- 
tient comes  under  his  charge  for  her  expected  confinement, 
point  out  to  her  at  every  opportunity  the  advantages  of 
maternal  nursing  and  the  dangers  of  bottle  feeding.  It  is 
a  grave  error,  too  often  committed,  to  discontinue  the  breast 
at  the  first  sign  of  indigestion  in  the  newborn, — an  occur- 
rence so  common  that  it  may  almost  be  regarded  as  normal. 
A  mother,  on  the  other  hand,  will  frequently  believe  that 
her  baby  is  not  getting  sufficient  nourishment  or  that  her 
milk  is  too  weak  or  too  rich,  and  that  altogether  she  is  unfit, 
both  from  her  own  and  the  standpoint  of  her  infant's  health, 

i  (1) 


2  BREAST   FEEDING. 

to  suckle  her  babe.  The  psychic  element,  represented 
by  fear  and  uncertainty  in  the  mother's  mind,  is  a  very  potent 
cause  for  the  discontinuance  of  maternal  feeding  and  is  ex- 
ceedingly difficult  and  sometimes  impossible  to  overcome. 
In  fact,  fear  and  anxiety  may  cause  a  temporary  suspension 
of  the  lacteal  flow,  just  as  oft  the  other  secretions, — saliva, 
for  instance.  The  physician  here  again  fails  in  his  func- 
tion if  he  thoughtlessly  coincides  with  the  mother's  ideas 
without  investigation.  True  it  is  that  there  are  contraindi- 
cations to  maternal  feeding,  but  these  will  really  be  found 
to  be  few.  In  our  zeal  to  secure  some  substitute  for  or 
imitation  of  human  milk,  we  have  been  carried  away  from 
the  truism  that  nothing  is  quite  so  good  as  the  real  article, 
and  that,  if  we  would  but  have  it,  there  is  plenty  of  it  at 
hand ;  and  that  the  study  of  its  conservation  is  perhaps  the 
most  urgent  duty  of  the  pediatrist  and  of  the  practitioner. 

The  best  guide  as  to  a  particular  woman's  ability  to 
nurse  is  the  physical  condition  of  her  babe.  Ifi  its  weekly 
gain  equals  from  5  to  7  ounces  or  even  a  little  less,  then 
nothing  else  need  be  considered.  In  spite  of  this,  on  the 
plea  that  the  milk  is  insufficient  in  quantity  and  quality, 
although  the  simple  process  of  weighing  the  infant  before 
and  immediately  after  nursing  for  a  few  times  was  not 
practised;  or  that  the  infant  failed  to  gain  weight  (even 
in  the  absence  of  a  milk  analysis)  ;  or  that  it  suffered  from 
digestive  disturbances,  physicians  are  daily  sacrificing  the 
human  milk-supply.  Granted  that  these  conditions  are 
realities,  one  may  pertinently  ask  "Do  they  constitute  a  suffi- 
cient reason  to  stop  breast  feeding?"  Certainly  not!  As 
will  be  pointed  out  later,  there  are  methods  of  conserva- 
tion and  of  correction  whereby  the  milk  can  be  increased 
in  quantity  or  whereby  any  or  all  of  the  various  elements 


MAMMARY   GLAND. 


may  be  augmented  or  diminished.  These  it  is  the  physi- 
cian's duty  to  know  and  to  practise.  The  mother,  on  her 
part,  should  look  to  her  medical  advisor  alone,  and  not  de- 
pend upon  the  gratuitous  advice  of  well-meaning  but  poorly 
informed  friends. 

Breast  feeding  may  be  done  either  by  the  mother  (ma- 
ternal nursing)    or  by  a   wet-nurse    (wet-nursing).     The 


Fig.  I. — The  mammary  gland.     (Gray.) 

former  is  by  far  the  more  satisfactory.  The  latter  is  useful 
in  emergency.  As  the  milk  is  secreted  by  the  mammary 
glands,  the  construction  and  function  of  these  organs  should 
be  understood. 

MAMMARY  GLAND. 

The  mammae,  or  breasts,  secrete  the  milk  and  are  two, 
large,  hemispherical  eminences  situated  on  the  lateral  aspect 
of  the  chest,  between  the  third  and  the  sixth  or  seventh  ribs, 
and  between  the  sternum  and  the  axilla  (Fig.  i).  They 


4  BREAST   FEEDING. 

vary  in  size  in  different  women  and  in  the  same  woman, 
depending  upon  the  physiologic  activity  of  the  uterus.  The 
left  breast  is  a  trifle  larger  than  the  right.  Before  puberty 
they  are  insignificant,  but  increase  in  size  as  the  generative 
organs  develop.  During  pregnancy  they  enlarge  and  re- 
main so  during*  active  lactation.  The  shape  of  the  organ, 
as  a  rule,  changes  from  a  circular  convex  outline  to  a  large, 
pendent  mass.  The  nipple  is  a  small,  conical  eminence 
placed  just  below  the  centre  of  the  gland.  The  skin  cover- 
ing the  nipple  and  surrounding  its  base  contains  pigment, 
the  amount  and  character  of  which  depend  upon  the  type 
of  woman  (blonde  or  brunette)  and  upon  the  activity  of 
the  gland.  This  pigment,  called  the  areola,  in  the  virgin 
is  of  a  delicate  rose  tint.  As  pregnancy  advances  it  becomes 
darker  and  spreads  over  a  larger  area,  extending  from  the 
base  of  the  nipple  over  the  surface  of  the  gland  (secondary 
areola). 

In  brunettes  of  pronounced  type  this  secondary  pig- 
mentation may  be  black.  The  skin  covering  the  surface 
of  the  gland,  besides  being  pigmented,  also  becomes  striated 
much  after  the  fashion  of  the  skin  of  the  abdomen.  The 
nipple  contains  involuntary  muscle-fibre,  which,  under  sex- 
.ual  excitement  or  the  irritation  produced  by  the  infant's  lips, 
contracts,  causing  the  nipple  to  become  erect.  The  nipple  is 
perforated  at  its  tip  by  the  numerous  orifices  of  the  galacto- 
phorous  ducts.  Around  the  base  of  the  nipple  are  found 
several  sebaceous  glands  which  serve  to  keep  the  skin  in  a 
pliable  condition  (glands  of  Montgomery).  Numerous 
nerves  find  their  endings  in  the  cutaneous  papillae  of  the 
nipple. 

Histologically  the  mammae  are  tubo-racemose  glands 
(Piersol),  containing  fifteen  to  twenty  lobes,  which  are 


MAMMARY   GLAND.  5 

separated  and  supported  by  masses  of  adipose  tissue  and  by 
fibrous  septa,  which  divide  the  lobes  into  lobules  and  these 
again  into  acini.  These  acini  are  lined  by  a  low  columnar 
epithelium,  which  varies  in  character,  depending-  upon  the 
functional  activity  of  the  gland.  These  cells,  resting  upon  a 
membrana  propria,  rapidly  multiply  and  oil-droplets  appear 
within  them.  These  gradually  increase  in  amount  and 
coalesce  until  they  occupy  almost  the  entire  content  of  the 
cell,  crowding  the  nucleus  and  the  protoplasm  to  one  side. 
As  the  amount  of  oil  increases  the  cells  become  distended 
and  finally  rupture,  the  oil  being  discharged  into  the  lumen 
of  the  acinus,  where,  becoming  mixed  with  an  albuminous 
secretion  and  epithelial  debris,  constitutes  the  secretion  of 
the  gland,  or  milk.  The  cells  near  the  centre  of  the  acinus 
undergo  fatty  degeneration  and  are  discharged  for  a  few 
days  following  the  establishment  of  lactation.  These  cells 
constitute  the  large  colostrum  corpuscles  (Fig.  6)  which 
persist  for  a  week  or  ten  days,  and  the  first  secretion  is 
known  as  colostrum.  The  milk  is  carried  off  by  means  of 
ducts  which  extend  from  each  acinus.  These  are  called 
lactiferous  ducts,  and  they  unite  with  those  from  other 
acini  and  form  the  lobular  duct  which  joins  with  those 
from  other  lobules,  and  finally  this  union  terminates  into 
the  lobar  duct  or  galactophorous  duct,  which  passes  as  a 
single  tube,  ununited,  from  each  lobe  and  opens  by  a  separate 
outlet  into  the  apex  of  the  nipple.  Just  before  it  reaches 
the  apex  of  the  nipple,  each  duct  dilates  into  a  pouch  or 
ampulla.  These  ampullae  act  as  reservoirs  for  the  milk. 
The  ducts  are  lined  with  low  columnar  epithelium  which 
rests  upon  a  membrana  propria,  and  each  duct  possesses  a 
fibrous  coat  which  contains  elastic  tissue  and  some  unstriped 
muscle-fibre.  As  the  ducts  approach  the  surface  of  the 


6  BREAST   FEEDING. 

nipple   the   lining-  epithelium   becomes   stratified    and   con- 
tinuous with  that  of  the  epidermis. 

The  internal  mammary,  the  thoracic  branches  of  the 
axillary,  and  the  intercostal  arteries  supply  these  organs 
with  blood,  and  their  branches  penetrate  the  entire  gland, 
even  surrounding  the  acini  in  a  capillary  network.  The 
venous  blood  from  the  interior  of  the  gland  is  carried  by 
venules  to  the  circulus  venosus  surrounding  the  nipple. 
Thence  large  branches  carry  the  blood  to  the  circumference, 
terminating  in  the  axillary  and  the  internal  mammary  veins. 
The  lymphatics  empty  for  the  most  part  into  the  anterior 
axillary  glands  and  some  few  into  the  anterior  mediastinal 
glands.  During  lactation  the  vascular  supply  to  the  mam- 
mae is  increased  and  the  veins  become  decidedly  prominent. 
The  anterior  and  lateral  nerves  of  the  thorax  supply  the 
mammae  with  innervation. 

HYGIENE  OF  THE  BREAST  AND  NIPPLES. 
After  each  nursing,  the  nipples  are  gently  cleansed  with 
a  piece  of  absorbent  cotton  moistened  with  boric  acid  solu- 
tion and  gently  dried.  The  infant's  mouth  is  cleansed  in  a 
similar  manner  with  a  mild  antiseptic  alkaline  solution.  Be- 
fore nursing  the  nipples  should  also  be  cleansed.  No  milk 
should  be  permitted  to  dry  or  to  sour  upon  the  nipple,  as 
digestive  disturbances  are  likely  to  follow  as  well  as  mam- 
mary infection.  Excoriations  and  fissures  of  the  nipples 
may  cause  excruciating  pain.  They  can  often  be  prevented 
by  bathing  the  parts  during  the  entire  period  of  gestation 
with  a  solution  of  alum  in  alcohol,  thereby  rendering  the 
epithelium  tough.  When  present,  temporary  suspension 
of  breast  feeding  may  become  necessary  for  a  few  days,  or 
the  artificial  nipple  may  be  employed  (Fig.  2).  Experience 


HYGIENE   OF   BREAST    AND    NIPPLES.  7 

with  this  instrument  is  not  always  satisfactory.  It  may 
annoy  the  mother,  and  the  infant  may  not  take  to  it  kindly. 
A  better  method  is  to  withdraw  the  milk  by  manual  manipu- 
lation, and  to  feed  it  to  the  baby  through  a  bottle  or  by 
means  of  a  spoon.  The  application  of  some  sedative  dusting 
powder,  as  equal  parts  of  bismuth  and  boric  acid,  is  often 


Fig.  2. — Artificial  nipple  or  nipple-shield. 

serviceable.  Before  nursing,  the  powder  should  be  care- 
fully wiped  away.  Indolent  fissures  are  stimulated  to  heal- 
ing by  touching  them  with  a  stick  of  silver  nitrate.  Com- 
presses wet  with  a  10  per  cent,  solution  of.argyrol  or 
ichthyol  are  also  useful.  Better  than  all  these  is  a  paste 
made  from  equal  parts  of  bismuth  subnitrate  and  castor  oil. 
An  ointment  of  calendula,  prepared  by  homeopathic  phar- 
macies, applied  to  the  sore  places,  has  often  yielded  good 
results. 


8  BREAST    FEEDING. 

ECZEMA  OF  NIPPLES  DURING  PUERPERIUM. 
Eczema  of  the  nipples  and  of  the  neighboring  integu- 
ment is  a  troublesome  complication  of  the  puerperium  and 
may  seriously  interfere  with  nursing.  Water  should  be 
kept  away  from  the  parts.  The  condition  usually  yields  to 
the  combination  of  castor  oil  and  bismuth.  If  there  be 
present  indurated  fissures,  salicylic  acid  gr.  x  and  lanolin 
3j  will  usually  cause  them  to  heal. 

DEPRESSED  NIPPLES. 

The  nipples  may  be  depressed  below  the  surface  of  the 
gland,  or  they  may  be  inverted  or  even  absent.  The  de- 
pression may  disappear  under  the  stimulus  of  sexual  excite- 
ment or  of  the  infant's  lips.  Depressed  or  inverted  nipples 
may  be  a  serious  handicap  to  maternal  feeding.  For  this 
reason  throughout  the  puerperium,  the  mother  should  be 
taught  to  daily  draw  the  nipple  out  with  her  fingers  or  with 
the  breast  pump.  It  is  surprising,  on  the  other  hand,  to  note, 
in  some  cases  wherein  the  galactophorous  ducts  open 
directly  upon  the  surface  of  the  glands  with  practically  no 
nipple,  with  what  ease  the  infant  seizes  the  breast  and 
maternal  feeding  is  successfully  accomplished. 

CAKING  AND  ABSCESS  OF  THE  BREAST. 
If  the  milk  enters  the  breast  too  rapidly,  or  if  it  fails 
to  be  withdrawn,  by  proper  nursing,  it  collects  in  the  lac- 
tiferous tubules  and  in  the  acini  of  the  mammary  gland, 
causing  them  to  distend.  This  is  known  as  caking.  The 
breast  becomes  exceedingly  painful  and,  especially  in  the 
dependent  portions,  are  felt  the  hard  and  tender  lobes  of 
the  gland.  Caking  is  best  prevented  by  regular  and  steady 
nursing.  If  in  spite  of  this  an  excess  of  milk  is  secreted, 


CAKING  AND  ABSCESS  OF  BREAST.        9 

the  breast  pump  (Fig.  3)  may  be  used  to  remove  the  excess, 
and  the  breasts  are  gently  massaged  with  warm  oil  several 
times  a  day,  care  being  exercised  to  make  the  stroke  in  the 
direction  of  the  ducts,  from  the  base  toward  the  nipple 
(Fig.  4,  A  andB). 

Abscess  of  the  breast  is  a  preventable  as  well  as  a  lament- 
able accident.  It  results  directly  from  mammary  infection. 
Infection  may  be  carried  into  the  lobules  of  the  glands 
through  cracks  in  the  nipple,  through  eczematous  excoria- 


Fig.  3- — Breast-pump.     (Physician's  Supply  Co.,  of  Phila.) 

tions,  by  the  mouth  of  the  infant,  and  by  the  decomposition 
of  milk  left  to  dry  upon  an  imperfect  nipple.  The  nurse 
or  physician  may  carry  infection  to  the  breast  by  undue 
manipulation. 

Symptoms.— Abscess  may  appear  at  any  time  during  the 
nursing  period.  It  is  more  common  during  the  earlier  weeks. 
There  may  be  few  if  any  constitutional  symptoms.  On  the 
other  hand,  the  general  reaction  may  be  severe,  the  patient 
complaining  of  chilly  sensations  or  suffering  a  real  rigor. 
The  temperature  rises  to  101°  F.  or  to  103°  F.  (rarely 
higher),  and  the  pulse  is  proportionately  increased.  Ano- 
rexia and  nausea,  as  well  as  headache  and  neuromuscular 
pains  occur.  The  tongue  is  coated  and  the  bowels  become 
constipated. 


10  BREAST   FEEDING. 

Locally  there  appears  a  small  or  a  large,  circumscribed 
spot  of  induration  which  is  tender  and  which  varies  in  size 
from  a  marble  to  a  walnut.  More  than  one  such  area  may 
thus  appear.  The  overlying  skin  becomes  bright  red.  It  is 
.not  at  first  adherent,  but  later  becomes  so.  The  color  dark- 
ens, the  area  softens,  often  increasing  to  an  enormous  size, 
spreading  not  only  superficially,  but  deeper  into  the  substance 
of  the  gland.  The  skin  is  hot,  the  pain  intense,  and  fluctua- 
tion is  made  out  with  ease  or  difficulty,  depending  upon  the 
depth  of  the  infection.  Spontaneous  rupture  may  occur  with 
a  disappearance  of  general  symptoms,  to  be  followed  by 
slow  healing  and  perhaps  one  or  more  remaining  sinuses, 
which  may  or  may  not  intercommunicate.  These  sinuses 
may  persist  for  months. 

Treatment. — Aside  from  incision  and  drainage,  as  soon 
as  fluctuation  manifests  itself,  the  effect  of  mammary  abscess 
upon  the  future  ability  of  the  mother  to  nurse  her  babe  must 
be  seriously  considered.  At  first  thought  it  would  appear 
that  a  mammary  gland,  once  infected,  is  lost  to  the  infant 
forever.  While  true  in  most  cases,  one  must  discriminate 
and  determine  each  case  individually.  The  size  and  the  posi- 
tion of  the  abscess,  and  also1  whether  or  not  pus  is  being 
secreted  at  the  nipple,  largely  influence  the  decision.  This 
may  be  recognized  by  the  naked  eye ;  or  bacteria,  pus  cells, 
and  perhaps  blood  may  be  discovered  by  the  microscope.  If 
the  other  breast  be  healthy  it  may  yield  sufficient  milk.  At 
least  partial  breast  feeding  should  be  employed.  If  on  the 
other  hand,  as  in  a  case  in  point,  in  which  the  abscess  was 
as  large  as  a  marble  and  in  which  no  pus  appeared  at  the 
nipple  by  reason  of  the  fact  that  the  galactophorous  duct 
leading  to  it,  between  it  and  the  abscess,  was  obliterated  by 
an  adhesive  inflammation,  the  infant  will  not  receive  any 


CAKING   AND   ABSCESS    OF    BREAST. 
A 


11 


Fig.  4. — Massaging  breast.     The  motion  starts  at  the  base  of  the 
organ  (A)  and,  by  a  circular  or  spinning  movement  of  the  hands,  ends 

at  the  nipple  (B). 


12 


BREAST   FEEDING. 


infected  material,  there  is  no  reason  why,  after  incision  and 
drainage,  nursing  should  not  go  on,  provided  the  nipple 
can  be  protected  (Fig.  5). 

Incision  into  a  mammary  abscess  should  be  made  in  a 
manner  radiating  from  the  nipple,  and  not  encircling  it,  in 
order  to  prevent  severing  of  the  healthy  ducts. 

Internally  the  mother  should  receive  a  gentle  laxative, 
as  cascara,  or  a  small  dose  of  castor  oil.  An  enema  may 


Fig-  5- — Abscesses  not  interfering  with  breast  feeding. 


suffice  to  open  the  bowels.  The  diet  is  limited  to  fluids, 
and  in  order  to  combat  toxemia  a  daily  enema  of  normal  salt 
solution  (to  be  retained)  or  continuous  rectal  proctoclysis 
are  valuable  adjuncts.  Head  and  body  pains  and  fever 
may  be  relieved  by  small  doses  of  aspirin,  codein  and  extract 
of  aconite  root.  If  the  mother  feels  too  ill  to  nurse  the 
infant,  it  may  be  temporarily  withdrawn  from;  the  breasts 
for  from  twenty-four  to  seventy-two  hours.  In  the  mean 
time  it  should  be  placed  upon  a  weak  mixture  of  condensed 
milk  and  water.  The  healthy  breast  should  be  massaged 
and  the  pump  applied  to  prevent  caking.  When  healing 


COLOSTRUM. 


13 


is  slow  search  should  be  made  in  the  mother  for  tuber- 
culosis or  for  some  depressing  diathesis.  Change  of  air, 
good  food,  Basham's  mixture  or  iron  citrate,  with  other 
tonics,  hypodermically,  should  be  used.  Autogenous  or 
stock  vaccines  should  also  be  employed  as  adjuvants. 


B 


Fig.  6. — Microphotograph  of  colostrum.    A,  the  large  nucleated 
and  granular  colostrum  corpuscles ;  B,  oil  globules. 

COLOSTRUM. 

About  the  third  day  of  the  puerperium  milk  makes  its 
appearance  in  the  mother's  breast.  This  first  lacteal  secre- 
tion is  not  really  milk,  but  consists  largely  of  water  and  is 
comparatively  rich  in  protein.  It  is  known  as  colostrum 
and  microscopically  contains  large,  granular,  corpuscular 
bodies,  about  five  times  the  size  of  milk-corpuscles.  They 
are  known  as  colostnwi  corpuscles,  and  probably  represent 
desquamated  epithelial  cells  which  line  the  acini  of  the  mam- 


14  BREAST   FEEDING. 

mary  gland  (Fig.  6).  Colostrum  also  contains  globules 
of  oil.  Its  composition  is  variable,  as  indicated  by  the  table 
of  Harrington,  quoted  by  Rotch : — 


Fat    

I 
1.40 

II 
0.68 

III 

2.40 

IV 
5-73 

V 
4.40 

Milk-sugar  and  pro- 
teins   

9-44 

H-53 

11.15 

10.69 

11.27 

Ash    

0.17 

0.31 

0.25 

0.16 

0.21 

Total  solids  

II.OI 

12.52 

13.80 

16.58 

15-88 

Water          

88.99 

87.48 

86.20 

83.42 

84.12 

IOO.OO      IOO.OO      IOO.OO      IOO.OO      IOO.OO 

As  indicated,  the  quantity  of  fat  is  comparatively  low; 
while  the  percentages  of  milk-sugar  and  of  proteins  are  high 
and  uniform.  The  function  of  colostrum  is  but  little  under- 
stood. It  probably  does  not  contribute  to  the  nutrition  of 
the  infant.  In  fact,  the  reverse  is  true,  for  during  the  first 
week  of  life  the  infant's  weight  is  diminished.  Its  effect 
is  probably  that  of  a  laxative,  ridding  the  bowel  of  meco- 
nium.  Colostrum  disappears  in  about  one  week  to  ten  days, 
and  is  replaced  by  true  milk. 

CHEMISTRY  AND  PHYSICS  OF  HUMAN  MILK. 

Human  milk,  as  well  as  cows'  milk,  is  an  emulsion.  It 
is  an  opaque  fluid,  bluish  white  in  appearance,  and  has  a 
sweet,  palatable  taste.  Its  reaction  is  alkaline  or  amphoteric 
when  freshly  drawn.  The  specific  gravity  varies  between 
1029  and  1030. 

Under  the  microscope  the  milk  is  seen  to  consist  of  a 
•fluid  portion  and  of  corpuscular  elements  (Fig.  7,  A). 
These  corpuscles  are  minute,  evenly  divided,  fat  globules, 
which  are  held  in  suspension.  When  milk  is  acted  upon 
by  rennin  and  slightly  warmed  it  coagulates.  The  coagu- 


CHEMISTRY  AND  PHYSICS  OF  HUMAN  MILK. 


15 


O  c     --  -   - 

~>v    O<      c  • Z         " 

P  ri'o       ' 

-  K^-x  P°  .    °  . 


-A 


Fig.  7.— Microphotograph  of  human  and  of  cows'  milk.  I.  Normal  human  milk 
showing  uniformity  in  size  of  fat  globules  (A).  The  apparent  smallness  in 
the  size  of  those  in  the  centre  is  due  to  the  focusing.  Note  the  absence  of 
epithelial  cells  and  leucocytes.  The  presence  of  the  latter  would  indicate  in- 
flammation of  the  breast,  probably  beginning  abscess.  II.  Cows'  milk  showing 
the  comparative  irregularity  in  the  size  (larger)  and  shape  of  the  fat  globules 
(A)  with  reference  to  human  milk.  Also  note  the  absence  of  epithelial  cells 
and  leucocytes,  showing  the  teat  to  be  free  of  inflammation. 


!6  BREAST   FEEDING. 

kirn  consists  of  calcium  paracasein  (casein)  or  principal 
protein  constituent  of  the  milk,  in  the  meshes  of  which 
are  contained  the  fat  globules.  In  the  normal  state  this 
protein  exists  as  calcium  casein  (caseinogen).  From  the 
coagulum  exudes  a  clear,  watery  fluid  called  whey.  Whey 
contains  the  soluble  and  non-coagulable  proteins,1  lact- 
albumin  and  lactoglobulin.  The  former  is  coagulated  by 
heat;  the  latter  is  not.  Whey  also  contains  the  salts  and 
sugar  of  milk  in  solution  and  a  small  amount  of  fat.  Two- 
thirds  of  the  protein  in  human  milk  are  lactalbumin  and 
lactoglobulin.  In  cows'  milk  but  one-fourth  of  the  total 
protein  is  composed  of  these  constituents. 

The  chemical  composition  of  human1  milk  varies.  It 
varies  in  different  women  and  in  the  same  woman  at  differ- 
ent periods  of  the  same  nursing  and  at  different  times 
throughout  the  entire  period  of  lactation.  The  composition 
varies  as  to  the  number  of  daily  feedings  and  the  length 
of  each  feeding.  It  also  depends  upon  the  character  and 
quantity  of  the  mother's  food,  her  environment,  tempera- 
ment, the  care  she  has  received  during  her  accouchement, 
and  the  amount  of  physical  exercise.  The  nearer  to  nature 
a  woman  lives,  the  more  normal  iinll  be  her  milk-supply. 

The  percentage  of  fat  is  the  most  variable  constituent. 
It  is  the  lightest  element  in  milk,  and,  if  the  milk  be  per- 
mitted to  stand,  it  rises  to  the  surface  and  constitutes  cream. 
Cream  does  not  consist  entirely  of  fat,  but  contains  the  other 
chemical  substances  found  in  milk.  According  to  Holt,  the 
ratio  of  the  fat  to  the  cream  is  as  3  is  to  5.  The  fats  of 
milk  are  composed  of  stearin,  olein,  and  palmitin,  and  are 
in  fixed  combinations,  the  amount  of  volatile  fatty  acids  be- 
ing decidedly  less  than  in  cows'  milk. 

1  Non-coagulable  with  reference  to  renin. 


PLATE  I 


Meconium. 


BACTERIOLOGY   OF   HUMAN   MILK.  17 

The  percentage  of  carbohydrates  (milk-sugar)  rises 
rapidly  after  the  first  few  days  of  lactation  and  gradually 
increases  to  the  end.  The  sugar  of  milk,  lactose,  is  a  white, 
crystalline  substance  obtained  by  the  evaporation  of  whey. 

The  proteins  are  plentiful  in  the  beginning,  but  gradu- 
ally diminish  as  lactation  draws  toward  the  close.  The 
same  is  true  of  the  salts,  which  consist  principally  of  the 
phosphates  of  sodium,  potassium,  calcium,  and  magnesium, 
and  the  chlorids  of  potassium  and  sodium  and  a  trace  of 
organic  iron. 

The  average  composition  of  human  milk  is  represented 
by  the  following  table: — 

ANALYSIS  OF  HUMAN  MILK. 

Proteins    1.5  to  2% 

Fat  3-5  to  4% 

Sugar    6     to  7% 

Ash   .  0.2  to  i% 


Total  solids  1 1.2  to  14% 

Water   .  .  88.8  to  86% 


100%     100% 

Reaction   Alkaline  or  amphoteric. 

Specific  gravity   1029  to  1030 

BACTERIOLOGY  OF  HUMAN  MILK. 
Human  milk  is  practically  sterile.  The  only  organisms 
which  are  found  under  healthy  conditions  are  those  which 
normally,  or  rather  for  the  time  being,  as  non-pathogenic 
germs,  inhabit  thd  skin.  These  represent  the  Staphylo- 
cocci  epidermidis  albus,  and  Pyogenes  albums,  citreus  and 
aureus.  In  the  presence  of  disease  of  the  gland  all  vari- 
eties of  pathogenic  bacteria  have  been  found.  The  typhoid 
bacillus  and  the  pneumococcus  have  been  recovered  in  cases 


18  BREAST   FEEDING. 

of  typhoid  fever  and  of  pneumonia,  as  well  as  the  tubercle 
bacillus  in  the  presence  of  local  tubercular  disease.  Roger 
and  Carrier  report  the  presence  of  tubercle  bacilli  in  breast 
milk  in  a  patient  who  died  of  pulmonary  and  laryngeal 
tuberculosis. 

ANALYSIS  OF  HUMAN  MILK. 

Sample. —  A  sample  of  milk  for  analysis  is  obtained  by  a 
breast  pump,  or,  better,  by  stripping  the  ducts  gently  and 


Fig.  8.— Stripping  of  breast  for  sample  by  running  the  thumb  and 
index-finger  from  the  periphery  to  the  base  of  the  nipple,  where  pres- 
sure is  exerted.  The  stream  thus  produced  is  caught  in  a  glass  until 
a  sufficient  amount  (about  an  ounce)  is  obtained  for  analysis. 

receiving  the  milk  into  a  glass  (Fig.  8).  The  first  milk 
may  be  discarded.  The  sample  should  consist  of  portions 
taken  throughout  the  day  at  different  times  of  the  nursing 
period,  and  should  be  secured  from  both  breasts.  This 
gives  an  average  of  the  milk  received  by  the  baby.  Breast 
pumps  are  of  several  kinds,  the  one  pictured  in  the  cut 
(Fig.  3)  being  the  most  familiar,  simple  in  construction, 
and  easily  cleansed.  As  a  rule,  however,  the  use  of  these 


ANALYSIS    OF   HUM  AX    MILK.  19 

instruments  is  tedious  and  unsatisfactory.     The  pump  and 
the  bottle  which  is  to  receive  the  sample  should  be  sterilized. 
The  color  of  human  milk  is  bluish  white  in  appearance. 
It  has  no  characteristic  odor. 

A  B 


Fig.  9. — Lactometer.     (Physician's  Supply  Co.,  of  Phila.) 

Reaction. —  This  is  tested  by  litmus-paper. 

Specific  Gravity. — This  is  determined  by  an  ordinary 
urinometer  or  a  special  lactometer  (Fig.  9).  The  milk  is 
put  into  a  small  cylinder,  A,  and  the  instrument,  B,  is  lowered 
into  the  former  with  a  slight  spin  to  avoid  sticking  to  the 


20  BREAST   FEEDING. 

sides.  When  it  has  come  to  rest  the  graduation  on  the 
neck  is  read.  The  temperature  of  the  milk  should  be  60°  F. 
The  specific  gravity  furnishes  crude  but  valuable  compara- 
tive data  for  clinical  purposes.  Thus  the  fat,  being  the 
lightest  constituent  of  milk,  when  in  excess  would  cause  the 
specific  gravity  to  be  low,  provided  the  other  solid  con- 
stituents were  normal.  Conversely,  under  the  same  condi- 
tions a  high  specific  gravity  would  indicate  that  the  per- 
centage of  fat  must  be  low.  If  the  percentage  of  fat  is 
normal  and  the  specific  gravity  is  high,  this  would  indicate 
that  the  remaining  solids  were  high.  The  reverse  means 
that  there  is  a  deficiency  of  the  other  solids.  Therefore,  too, 
if  the  specific  gravity  be  normal  and  the  fats  are  high,  the 
other  solids  are  high.  If  the  fat  be  low  and  the  specific 
gravity  is  normal,  then  the  other  solids  are  low. 

TABLE  SHOWING  RELATION  OF  KNOWN  PERCENTAGE  OF  FAT  AND  SPECIFIC 
GRAVITY  TO  REMAINING  SOLIDS. 

High    fat   and  normal   specific  gravity  =  High  remaining  solids. 

Low  fat  and  normal  specific  gravity  =  Low    remaining  solids. 

High  fat  and  high  specific  gravity  =  High  remaining  solids. 

Low  fat  and  high   specific  gravity  =  Low    remaining  solids. 

High    fat  and  low  specific  gravity  =  Low    remaining  solids. 

Low  fat  and  low  specific  gravity  =  Low   remaining  solids. 

Daily  Quantity  Secreted.—  This  is  with  difficulty  deter- 
mined, and  can  only  be  estimated  by  weighing  a  baby  which 
is  gaining  steadily,  before  and  after  each  feeding  through- 
out the  entire  twenty-four  hours.  From  several  such  daily 
assays  an  average  can  be  struck.  The  following  table  from 
Holt1  gives  approximate  quantities  which  may  serve  as  a 
guide : — 


1  Holt,  "Diseases  of  Infancy  and  Childhood,"  page  130,  6th  edition. 


ANALYSIS    OF   HUMAN    MILK.  21 

Ounces.  Grams. 

At  the  end  of  the  first  week  10  to  16  300  to  500 

During  second  week   13  to  18  400  to  550 

During  third   week    14  to  24  430  to  720 

During  fourth  week    16  to  26  500  to  800 

From  the  fifth  to  thirteenth  week    20  to  34  600  to  1030 

From  the  fourth  to  sixth  month   24  to  38  720  to  1150 

From  the  sixth  to  the  ninth  month   30  to  40  900  to  1220 

Determination  of  Fat. — The  simplest  method  is  by  the 
cream  gauge  devised  by  Holt  (Fig.  10).  The  only  objec- 
tion to  its  use  is  that  it  requires  twenty-four  hours.  The 
instrument  is  graduated  into  100  parts  and  is  fitted  with  a 
ground-glass  stopper.  It  is  filled  to  the  zero  mark  with 
milk,  and  is  allowed  to  stand  for  twenty-four  hours  at  room 
temperature.  The  volume  occupied  by  the  cream  is  then 
read  off.  The  percentage  of  fat  to  the  cream  is  as  3  is  to  5. 
This  mathematical  formula  is  arbitrary.  The  results,  how- 
ever, are  useful  for  practical  purposes,  as  it  is  possible  to 
learn  whether  an  increase  or  a  diminution  has  taken  place, 
provided  a  record  of  each  examination  is  kept. 

A  simple  and  accurate  method  is  the  test  of  Babcock. 
Place  in  the  special  percentage  centrifuge  tube  (Fig.  n), 
by  means  of  a  graduated  pipette  (Fig.  12),  17.6  c.c.  of  milk. 
Clean  the  pipette  and  add  17.6  c.c.  of  strong  sulphuric  acid, 
holding  the  percentage  tube  in  an  inclined  position.  The 
acid  sinks  to  the  bottom.  Mix  the  two  liquids  by  means  of 
a  rotary  motion.  The  mixture  becomes  dark  brown  or 
black,  and  hot.  The  sulphuric  acid  dissolves  the  calcium 
paracasein,  and  the  heat  generated  is  sufficient  to  liquefy 
the  fat.  Place  the  percentage  tube  and  contents  in  a  centri- 
fuge and  rotate  1200  times  a  minute  for  six  minutes.  Now, 
by  means  of  the  pipette,  run  enough  hot  water  into  the  per- 
centage tube  to  bring  the  level  of  the  fluid  up  to  the  highest 
graduation.  Rotate  again  in  the  centrifuge  for  two  minutes. 


22 


BREAST   FEEDING. 


Note    on    the    graduated    neck    the    volume    occupied    by 
the  fat.     Each  unit  division  indicates  one  unit  per  cent. 


Fig.  ii.— Babcock's  centrifuge 
Fig.   10. — Creamometer   for  estimating    tube  for  estimating  fat.     (Ar- 
percentage  of  fat.     (Holt.)  thur  H.  Thomas  Co.) 

Readings  can  be  made  to  one-fourth  of  I  per  cent.   (0.25 
per  cent). 

Determination  of  Proteins. —  If  the  specific  gravity  and 
the  percentages  of  fat,  sugar,  and  salts  be  known,  the  per- 


ANALYSIS    OF   HUMAN    MILK. 


23 


centage  of  proteins  may  be  calculated  from  the  percentage 
of  total  solids.     The  total  solids  equal  the  sum  of  one- 


Fig.  12. — Babcock's  pipette 
for  estimating  fat. 


Fig.  13. — Eschbach's  albuminometer 
used  in  protein  test.  (Arthur  H. 
Thomas  Co.) 


fourth  of  the  last  two  figures  of  the  specific  gravity,  plus 
six-fifths  of  the  percentage  of  fat,  plus  0.14.  This  may  be 
expressed  as  follows: — 


24  BREAST   FEEDING. 

Last  two  figures  of  S.  Gr.       (%  of  fat  X  6) 

Total  solids  = •  +  -+.14 

4  5 

This  result  minus  the  sum  of  the  percentages  of  fat, 
sugar,  and  salts  equals  the  percentage  of  proteins. 

Example. — The  specific  gravity  is  1030.  The  percentage 
of  fat,  sugar,  and  salts  is,  respectively,  4,  7,  and  0.2. 

30      (4  X  6) 

Total  solids  =  —  +  -       —  +  .14=  12.44% 
4  5 

Percentage  of  proteins  =  12.44%  —  (4%  +  7%  +  0.2%) 
=  12.44%  —  11.2%  =  1.24%. 

A  more  accurate  method  is  that  described  by  Kjeldahl, 
but  is  too  complicated  for  practical  purposes. 

The  following  method  provides  accurate  comparative 
data.  The  solution  required  consists  of 

Phosphotungstic  acid,  25  Gm. 
Distilled  water,  125  c.c. 

After  thorough  solution  is  obtained,  add 

Hydrochloric  acid,  concentrated,  25  c.c. 
Distilled  water,  100  c.c. 

The  solution  if  kept  in  a  blue  bottle  will  remain  stable  for 
a  long  while.  Human  milk  is  diluted  I  to  10,  or,  if  the 
protein  is  thought  to  be  very  low,  I  to  5.  The  diluted  milk 
is  poured  into  an  Esbach  tube  such  as  is  used  for  the  estima- 
tion of  albumin  in  urine  (Fig.  13)  to  the  mark  U.  The 
solution  is  added  to  the  mark  R;  the  tube  corked  and  slowly 
inverted  12  times.  It  is  allowed  to  remain  upright  for 
twenty-four  hours,  and  the  percentage  of  protein  is  read 
at  the  level  of  the  precipitate. 

Estimation  of  Lactose. — The  calcium  casein  is  precipi- 
tated by  acidulating  the  milk  with  acetic  acid,  and  the 


INDICATIONS   FOR   MILK   ANALYSES.  25 

lactalbumin  by  boiling  the  acidulated  mixture.  Filter. 
Wash  the  precipitate  with  a  measured  quantity  of  distilled 
water,  which  is  added  to  the  nitrate.  When  cool,  place  in  a 
burette  and  titrate  with  Fehling's  solution,  as  when 
examining  urine.  The  reduction  factor  for  lactose  differs 
from  that  of  glucose,  10  c.c.  of  Fehling's  solution  being 
equivalent  to  0.06  Gm.  of  lactose,  instead  of  0.05  Gm.  of 
glucose. 

Microscopic  Appearance. — Human  milk  contains  great 
numbers  of  small  fat  globules  of  uniform  size  floating  in 
the  watery  portion  of  the  milk  (Fig.  7,  I).  Thus,  it  is 
seen  to  be  a  perfect  emulsion.  No  other  cellular  elements 
aside  from  an  occasional  epithelial  cell  or  a  leucocyte  are 
seen.  The  last  two  appearing  in  excess  indicate  an  abnor- 
mality, usually  inflammation  or  abscess. 

INDICATIONS  FOR  AND  INTERPRETATION  OF 
MILK  ANALYSES. 

For  clinical  purposes  it  is  proper  to  inquire  "When  do 
conditions  arise  that  demand  or  which  would  be  benefited 
by  a  careful  analysis  of  the  milk  which  the  infant  is  re- 
ceiving, and  boiw  are  these  results  to  be  interpreted?" 
Unless  there  be  a  distinct  indication,  the  interest  attached 
to  such  an  examination  is  purely  academic,  and  serves  no 
practical  purpose.  On  the  other  hand,  if  the  infant  is  not 
thriving,  or  if  there  be  evidences  of  indigestion  and  colic, 
or  if  the  mother  doubts  the  good  quality  of  her  milk, 
analyses  are  of  use.  "If  the  analysis  shows  the  milk  to  be 
poor  in  all  its  constituents,  does  this  mean  that  it  is  an  unfit 
food  for  the  particular  baby  receiving  it?"  Not  necessarily. 
The  best  guide  is  the  condition  of  the  baby  itself,  and  not 
infrequently  is  it  seen  that  an  infant  will  gain  steadily  on 


26  BREAST    FEEDING. 

what  appears  to  be  a  weak  milk,  while  another  will  not 
thrive  on  a  rich  one.  If,  however,  there  exists  a  combina- 
tion of  an  undernourished  babe  together  with  a  poor  milk, 
the  indication  is  clear  to  improve  the  quality  of  the  mother's 
milk  or  to  try  mixed  feeding,  or,  as  a  last  resort,  artificial 
feeding  alone. 

The  value  of  a  milk  analysis,  in  determining  which  of 
the  food  elements  of  the  breast  milk  are  responsible  for  the 
symptoms  of  indigestion,  is  incalculable,  and  often  is  the 
means  of  saving  to  the  infant  the  maternal  milk.  The  in- 
formation thus  obtained  frequently  permits  the  physician 
to  speedily  correct  the  trouble  through  treatment  of  the 
mother. 

Psychic  influences  exert  a  tremendous  effect  upon  the 
secretion  of  breast  milk,  and  if  a  milk  analysis  will  con- 
vince a  doubting,  fearful,  though  willing  woman,  that  her 
milk  is  of  good  quality,  the  time  consumed  and  the  expense 
will  have  been  well  worth  while. 

ADVANTAGES  OF  BREAST  FEEDING. 

In  his  daily  contact  with  his  patients  the  general  practi- 
tioner meets  no  question  with  more  frequency  than  that  deal- 
ing with  the  nutrition  of  the  infants  under  his  charge.  His 
responsibility  has  been  indicated  already  with  reference  to 
the  necessity  of  attempting  the  conservation  of  the  human 
milk-supply.  The  question  may  very  properly  be  asked, 
"What  are  the  advantages  of  breast  feeding?"  They  in- 
volve both  the  mother  and  the  infant,  and  if  the  physician 
has  the  facts  ready  at  hand,  many  converts  to  the  ranks  of 
those  who  suckle  their  young,  and  thereby  serve  as  a  potent 
instrument  in  lowering  infant  mortality,  will  be  gained  by 
him. 


ADVANTAGES   OF   BREAST   FEEDING.  27 

Gastrointestinal  and  nutritional  diseases  are  responsible 
for  55.5  per  cent,  of  all  the  deaths  which  occur  in  infants 
during  the  -first  year  (Holt}.  Practically  all  of  these  are 
artificially  fed.  This  should  be  sufficient  argument  to  en- 
courage both  physician  and  mother  to  conserve  the  milk- 
supply,  and  should  at  once  take  the  right  from  both  or 
either  to  arbitrarily  decide  whether  the  infant  should  re- 
ceive the  breast  or  not.  It  makes  the  obligation  mandatory. 
Too  frequently  the  breast  is  sacrificed  because,  without 
investigation,  carelessly  and  heedlessly  the  physician  or  the 
mother,  or  the  former  yielding  to  the  wishes  of  the  latter, 
decides  that  the  milk  is  unfit  food  for  the  baby.  A  woman 
may  declare  for  a  whim  that  she  does  not  want  to  nurse  her 
infant;  that  it  will  interfere  with  her  social  duties;  that 
it  is  not  aesthetic;  that  Doctor  So-and-So  knows  how  to 
feed  babies  artificially,  and  that  she  will  put  her  infant 
under  his  care;  that  she  has  a  friend  who  reared  a  baby  on  a 
popular  patented  food,  and  that  she  will  do  the  same. 
These  and  many  others  are  the  reasons  for  withdrawing  the 
breast.  Neither  physician  nor  layman  possesses  an  inherent 
right  to  destroy  a  helpless  babe's  means  of  sustenance. 
The  obligation  of  marriage  and  motherhood  carries  with  it 
to  the  healthy  woman  the  obligation  of  maternal  nursing 
for  nine  months  at  least. 

Digestive  disturbances  occur  with  less  frequency  and 
with  less  severity  in  the  breast-fed.  They  are  usually  of 
no  consequence,  and  seldom  are  associated  with  nutritional 
disturbance.  Breast  milk  possesses  antirachitic  and  anti- 
scorbutic properties  not  found  in  any  other  food.  In 
human  milk  there  probably  exists  certain  substances  which 
confer  upon  the  infant  a  natural  immunity  against  the  acute 
infectious  diseases,  as  these  occur  with  extreme  rarity  dur- 


28  BREAST   FEEDING. 

ing  the  first  year,  especially  in  the  breast-fed.  On  the 
other  hand,  their  incidence  in  this  class  of  patients  is 
marked  by  less  severe  symptoms  and  recovery  is  the  rule. 
In  the  breast-fed  dentition  is  rarely  troublesome.  Breast 
babies  gain  regularly  in  weight,  sleep  well,  and  are  happy. 
The  so-called  dreaded  second  summer  does  not  exist  for 
the  naturally  fed  infant,  and  danger  of  milk  infection  is 
absent.  The  food  is  always  practically  sterile,  of  the 
proper  temperature,  and  requires  no  preparation. 

From  the  mother's  standpoint  the  knowledge  of  having 
a  healthy  child  should  be  sufficient  compensation  for  any 
material  inconvenience  which  she  fears  she  might  have 
to  endure.  Some  women  honestly  think  they  cannot  nurse 
their  infants  or  that  their  food  is  insufficient,  consequently 
they  discontinue  nursing  or  use  other  foods  in  conjunction 
with  it.  It  is  difficult  to  convince  these  women  as  to  the 
fallacy  in  their  idea,  and  they  go  from  one  physician  to 
another  until  they  find  one  who>  places  the  baby  upon 
"modified"  milk.  This  usually  disagrees,  and  when  the 
infant  has  passed  the  gamut  of  all  the  patent  foods  and 
summer  diarrhea  it  is  returned  to  the  specialist,  dyspeptic 
and  marantic,  to  be  remodeled. 

If  feeding  be  conducted  with  system  and  regularity,  the 
nursing  mother  will  not  be  prevented  from  attending  to  her 
other  duties.  Between  nursings  she  may  rest,  and  go  out, 
and  after  three  months  the  baby  may  be  trained  to  sleep 
from  8  P.M.  until  6  A.M.  The  mother  should  not,  on  the 
other  hand,  be  permitted  to  deceive  herself  with  the  idea 
that  bottle  feeding  is  easier  than  breast  feeding.  Aside 
from  the  uncertainty  and  dangers  associated  therewith,  the 
former  requires  considerably  more  time  on  account  of  the 
necessity  of  preparation.  This,  taken  in  connection  with 


PLATE  II 


Normal  breast  stool. 


INDICATIONS  OF  UNSUCCESSFUL  FEEDING.  29 

the  inconvenience  caused  by  sickness,  places  artificial  feed- 
ing at  a  decided  disadvantage. 

INDICATIONS  OF  SUCCESSFUL  FEEDING. 

A  baby  thriving  on  the  breast  up  to  the  first  six  months 
should  gain  from  5  to  7  ounces  a  week.  It  may  be  a  little 
less  or  a  little  more.  After  this,  while  progressive,  the 
weekly  increase  is  less.  The  normal  stool  of  a  breast-fed 
infant  is  yellow,  smooth,  mushy,  and  free  of  particles  and 
of  mucus  (Plate  II).  It  has  a  pleasant,  slightly  acid 
odor,  and  is  weakly  acid  in  reaction.  The  bowels  move 
from  one  to  four  times  a  day.  Vomiting  does  not  occur. 
The  infant  may  regurgitate  a  little  food  just  after  feeding 
or  when  unduly  handled.  Unless  viciously  trained,  it  is 
happy,  contented,  does  not  cry,  sleeps  peacefully  between 
feedings,  and  awakens  regularly  at  feeding  time. 

INDICATIONS  OF  UNSUCCESSFUL  FEEDING. 

If  the  infant  does  not  thrive,  if  its  gain  in  weight  is 
small  or  unsteady,  or  it  does  not  gain  at  all;  if  it  vomits, 
has  indigestion,  is  fretful  and  sleeps  poorly,  the  cause  will 
rarely  lie  in  the  mother's  milk.  More  commonly  there  will 
be  found  some  error  in  training,  or  the  infant  has  received 
other  food  in  addition,  or  is  suffering  from  some  organic 
disease  of  the  gastrointestinal  canal.  Very  commonly  breast 
babies  may  be  constipated,  and  the  mothers  are  in  the  habit 
of  daily  using  an  injection  or  a  suppository.  Not  only  is 
this  unnecessary,  but  in  many  instances  is  directly  respon- 
sible for  the  inauguration  and  continuance  of  constipation. 
The  mother  should  be  taught  to  allow  the  infant  to  go 
thirty-six  hours  before  resorting  to  laxatives,  suppositories, 
or  injections.  At  the  end  of  this  time,  and  usually  before, 


30  BREAST   FEEDING. 

the  baby  will  have  had  an  evacuation.  Before  the  breast 
is  withdrawn  as  the  cause  of  trouble,  every  other  possible 
etiologic  factor  must  be  investigated. 

MOST  COMMON  CAUSES  OF  FAILURE  OF  MILK-SUPPLY 
AND  HOW  TO  PREVENT  THEM. 

From  the  day  that  she  places  herself  under  her  physi- 
cian's care  the  prospective  mother  must  not  only  be  taught 
the  importance  of  breast  feeding,  but  more  forcibly  still 
must  she  have  impressed  upon  her  her  ability  to  accomplish 
the  act.  Psychic  phenomena,  doubt  and  fear,  especially, 
that  the  milk-supply  is  insufficient  in  quality  o<r  quantity  or 
both,  as  before  stated,  are  often  responsible  for  the  suspen- 
sion of  the  flow.  Such  a  case  recently  came  to  notice  in 
which  by  persistent  persuasion  it  was  possible  to  carry  the 
mother  along  for  four  months  during  the  summer.  Her 
milk-supply  was  scant.  Each  week  she  asked  her  physician 
for  a  formula,  and  each  time  was  refused  because  her  baby 
gained.  In  the  fall,  after  weaning  had  been  accomplished, 
she  complained  of  an  overabundance  of  milk,  and  means 
had  to  be  taken  to  dry  it  up.  Once  the  element  of  fear  was 
removed,  her  milk-flow  became  plentiful.  Shock,  fright,  or 
sudden  joy  may  temporarily,  but  rarely  permanently,  impair 
the  flow.  Insufficient  rest,  a  continuous  round  of  social 
pleasures,  excessive  indulgence  in  alcohol,  too  much 
physical  work  and  too  little  food,  together  with  poverty, 
especially  where  the  mother  must  go  out  to  assist  in  earning 
her  living, — all,  by  interfering  with  the  proper  metabolism 
of  the  maternal  organism,  inhibit  or  prevent  the  mammary 
secretion. 

Any  condition  that  causes  a  sudden  or  continuous  loss 
of  blood  or  of  the  other  body  fluids  seriously  menaces  the 


CAUSES  OF  FAILURE  OF  MILK-SUPPLY.  31 


Fig.  14. — Types  of  good  nursing  breasts. 


32  BREAST   FEEDING. 

success  of  breast  feeding.  Of  these,  hemorrhage  from  the 
uterus,  either  at  the  time  of  labor  or  following  it,  especially 
in  those  cases  which  are  permitted  to  arise  from  bed  too 
soon,  is  a  most  potent  factor.  These  cases  are  lamentable 
since  they  are  preventable.  Every  labor  case  should  be  kept 
in  bed  at  least  two  weeks,  and  in  her  room  a  week  longer. 
If  she  start  to  bleed,  she  must  be  returned  to  bed  and  the 
source  of  the  trouble  sought.  Menstruation  occurring  dur- 
ing lactation  may  or  may  not  cause  disturbances.  Profuse 
vomiting,  sweating,  diarrhea,  and  excessive  diuresis  may 
destroy  the  supply.  The  remedy  here  is  obvious — preven- 
tion if  possible  or  cure  as  rapidly  as  can  be  accomplished. 
Chronic  constitutional  diseases  may  impair  the  quality  of  the 
milk  in  some  instances,  while  in  others  it  is  remarkable  how 
the  quantity  and  quality  both  may  be  maintained.  Nursing 
women  should  be  protected  from,  infection  of  all  kinds. 
Congenital  deficiency  of  glandular  substance,  especially  in 
very  fat  women,  is  a  serious  condition,  and  very  often 
cannot  be  overcome.  The  woman  who  has  an  abundance  of 
milk  is,  as  a  rule,  thin  and  wiry,  with  breasts  that  are  some- 
what pendulous,  free  of  fat,  and  full  of  lobules  which  can 
be  readily  palpated  (Fig.  14,  A  and  5).  Local  disease  of 
the  nipple,  eczema,  excoriations,  cracks  and  fissures,  as  a 
rule,  may  be  prevented  or  yield  rapidly  to  treatment. 

METABOLIC  AND  DIGESTIVE  DISTURBANCES  AND 
THEIR  MANAGEMENT. 

During  their  first  month  nearly  all  breast  babies  suffer 
from  indigestion.  Few  escape  it.  Some  continue  to  have 
it  throughout  the  nursing  period.  Some  present  subjective 
symptoms.  Some  do  not.  The  latter  are  in  the  majority. 
Some  lose  weight.  Most  of  them  continue  to  gain.  The 


PLATE  III 


Normal  stool  of  artificially  fed  baby. 


METABOLIC  AND  DIGESTIVE  DISTURBANCES.          33 

symptoms  are  largely  objective  and  may  be  referred  to  the 
stomach  and  bowels.  Vomiting  in  the  suckling,  as  the 
direct  result  of  dyspepsia,  depends  largely  upon  excessive 
individual  feedings,  too  frequent  feeding,  undue  handling, 
and  upon  an  excess  of  fat  or  sugar  in  the  mother's  milk. 
Food  comes  up  unchanged  when  vomiting  occurs  immedi- 
ately after  feeding,  or,  if  appearing  an  hour  or  two  later,  it 
is  sharply  acid,  smells  like  rancid  butter,  and  is  yellowish 
white  in  appearance.  Excessive  fat  also  causes  loose 
bowels,  which  may  contain  considerable  mucus.  The  move- 
ments average  from  four  to  five  a  day,  are  usually  yellow, 
occasionally  green,  and  contain  white  masses  that  resemble 
softly  fried  white  of  egg  which  has  been  chopped  up  and 
scattered  throughout  the  yellow  mass  (Plate  IV).  These 
white  masses  are  soluble  in  ether,  readily  burn,  and  are 
turned  black  by  osmic  acid.  These  babies  usually  have  some 
colic  and  may  be  fretful  and  irritable.  If  the  stool  be  placed 
in  water,  oil-drops  float  upon  the  surface.  Sudan  III,  as 
stated  elsewhere,  has  an  affinity  for  fat,  staining  it  a  bright 
red. 

If  there  be  a  deficiency  of  fat,  the1  infant  fails  to  gain, 
becomes  constipated,  irritable,  and  if  the  condition  con- 
tinues, rickets  is  a  common  sequence. 

Indigestion  depending  upon  an  excess  of  sugar  is  marked 
by  a  sour,  watery  vomitus  which  bums  the  infant  and  causes 
it  to  cry.  The  bowels  are  loose  and  watery,  highly  acid,  and 
excoriate  the  anus  and  buttocks.  Colic  is  comrnon.  The 
temperature  may  reach  several  degrees  above  normal. 

A  deficiency  of  sugar  causes  subnormal  temperature, 
loss  of  weight,  irritability,  and  constipation. 

Protein  excess  may  or  may  not  be  associated  with  vomit- 
ing of  curds.  Most  commonly  the  bowels  are  loose  and 


34  BREAST   FEEDING. 

contain  yellowish-white  masses  which  are  tough  and  which 
react  to  the  test  for  protein  (xanthoproteic).  The  move- 
ments (Plates  IV  and  V)  are  green  or  yellow  or  yellow- 
ish green,  and  contain  some  mucus.  The  constipated  dry, 
crumbly  movement  of  protein  excess  (Plate  VIII)  is  not 
met  with  in  the  breast-fed. 

A  deficiency  of  protein  means  underdevelopment,  sta- 
tionary or  decreasing  weight,  late  walking,  late  dentition, 
anemia,  asthenia,  constipation,  and  irritability.  The  con- 
dition may  pass  on  to  rickets. 

An  excess  of  mineral  matter  causes  diarrhea;  a  defi- 
ciency, constipation  and  scurvy. 

Treatment. — The  most  important  thing  to1  remember  is 
that  when  symptoms  of  indigestion  or  of  metabolic  disturb- 
ances occur  in  the  breast-fed,  the  first  thing  not  to  do  is  to 
take  the  child  from  the  breast.  This  is  commonly  done,  and 
from  this  time  on  dates  the  beginning  of  many  cases  of 
fatal  diarrhea  and  inanition.  Indigestion  in  the  breast-fed 
is  not  a  serious  condition,  and  usually  lends  itself  readily  to 
intelligent  management.  The  essential  thing  is  to  watch  the 
infant's  weight  from  week  to  week,  and  its  development. 
If  it  shows  a  steady  gain  no  change  should  be  made.  In 
any  case,  the  breast  should  not  be  given  up  without  at  least 
one  month's  observation.  In  the  mean  time,  if  the  symp- 
toms be  severe,  an  initial  purge  of  castor  oil  may  be  given, 
although  this  is  not  often  necessary  unless  the  symptoms  of 
colic  be  unusually  severe.  A  hunger  period,  allowing  only 
weak  tea  sweetened  with  saccharin,  gr.  j  to  the  quart,  an- 
swers best,  and  an  earnest  attempt  should  be  made  to'  modify 
the  mother's  milk  (Chapter  IX).  If  any  of  the  ingredients 
are  in  excess,  especially  the  fat  or  protein,  a  little  plain 
water  or  barley-water,  well  diluted,  should  be  given  ten 


MODIFICATION    OF   MATERNAL   MILK.  35 

minutes  before  feeding  time  in  order  to  dilute  the  milk. 
More  troublesome,  and  no  more  useful,  is  the  withdrawal 
of  the  milk  from  the  breast,  diluting  it  and  feeding  it  from 
a  bottle.  Colic,  if  troublesome,  is  usually  relieved  by  the 
castor  oil,  or  by  5  to  10  drops  of  the  aromatic  fluidextract 
of  cascara,  or  by  5  to  10  drops  of  essence  of  peppermint  in 
hot  water,  or  half  a  dram  to  a  dram  of  aqua  camphorse  or 
aqua  menthae  sodse  (soda  mint)  in  conjunction  with  the 
hunger  period.  A  spice  poultice  is-  soothing  if  applied  to 
the  belly.  The  same  quieting  effect  may  be  secured  by  a 
warm  asafetida  enema  or  10  to  30  mm',  of  the  milk  of 
asafetida  by  the  mouth.  After  feeding,  the  following 
powder  may  be  of  service : — 

Extract  of  pancreatin  (Fairchild's)    gr.  j  to  gr.  ij. 

Taka  diastase   (P.  D.  &  Co.)    gr.  j  to  gr.  ij. 

Sac.  lactis   gr.  v. 

In  cases  with  subnormal  temperatures,  external  heat  and 
massage  with  plain  or  with  codliver  oil  are  useful. 

The  further  treatment  includes  an  intelligent  modifica- 
tion of  the  mother's  milk  based  upon  a  correct  diagnosis  as 
to  which  of  the  ingredients  of  the  milk  are  at  fault. 

MODIFICATION  OF  MATERNAL  MILK. 

It  has  been  shown  how  maternal  milk  may  disagree 
with  an  infant  owing  to  an  excess  or  to  a  deficiency  in  any 
one  of  its  chemical  constituents.  Such  a  contingency  may, 
at  times,  be  overcome  by  the  use  of  certain  hygienic  meas- 
ures which  have  the  power  of  influencing  the  composition 
of  the  milk. 

Excess  of  Fat. —  This  is  a  matter  of  individual  idiosyn- 
crasy. In  reaching  a  conclusion  the  result  of  the. analysis 
may  not  be  taken  alone.  One  infant  may  show  disturbance 


36  BREAST    FEEDING. 

on  2  per  cent,  fat  and  another  may  tolerate  5  to  6  per  cent. 
Give  the  mother  a  morning  purge,  preferably  Epsom  salts. 
Increase  her  liquids,  especially  water  and  weak  tea.  In- 
crease her  exercise.  Lessen  somewhat  the  amount  of  all 
food,  especially  milk,  removing  the  cream  from  it  in  some 
cases.  Cut  down  the  proteins  (beef,  peas,  and  beans)  and 
the  fat  in  her  diet. 

Deficiency  of  Fat. — Control  diarrhea,  lessen  exercise, 
and  increase  the  beef  and  other  proteins,  and  fat  of  her  diet. 
Make  her  drink  freely  of  rich  milk.  Give  tonics  and  diges  • 
tants  to  improve  the  maternal  appetite.  The  addition  to  the 
diet  of  some  preparation  of  malt  or  the  weaker  alcoholic 
beverages  containing  malt,  such  as  porter,  beer,  and  stout, 
is  beneficial.  Southworth's  soup  made  by  boiling  I  or  2 
tablespoonfuls  of  cornmeal  in  a  quart  of  water,  to  which 
some  palatable  flavoring  has  been  added,  when  taken  daily, 
is  not  only  an  efficient  galactogogue,  but  increases  the  fat  of 
the  milk.  A  proprietary  preparation  known  as  Maltropon 
also  yields  good  results. 

Excess  of  Protein. — Increase  the  exercise.  Increase 
fluids,  especially  water  (2  to  3  quarts  a  day).  Relieve  con- 
stipation. Reduce  vegetable  and  animal  protein. 

Deficiency  of  Protein. — Give  tonics,  as  iron  and  phos- 
phates. Lessen  the  exercise.  Lessen  water -and  other  fluids. 
See  that  the  diet  contains  plenty  of  milk,  beef,  peas,  and 
beans.  Give  Southworth's  soup  and  Maltropon. 

Excess  of  Sugar. — Remove  carbohydrates  from  the  diet 
and  prohibit  the  use  of  candy  and  rich  desserts.  Increase 
the  fluid  intake.  Increase  the  exercise.  Give  an  occasional 
saline. 

Deficiency  of  Sugar. — Increase  the  carbohydrates,  espe- 
cially sugar.  Lessen  the  amount  of  water.  Lessen  the 


PLATE  TV 


Stool  of  indigestion  in  the  breast-fed.  Note  white  masses  (fat  and 
protein),  mucus,  and  admixture  of  green  and  yellow  color.  A  very  com- 
mon and  important  stool  in  the  breast-fed.  It  does  not  call  for  a 
discontinuance  of  the  breast  milk,  as  so  many  mothers,  nurses,  and 
physicians  seem  to  think.  If  the  infant  gains  in  weight,  this  stool  should 
be  ignored.  It  can  be  made  normal  by  careful  regulation  of  the 
mother's  diet,  plenty  of  water,  a  reduction  in  her  milk,  meat,  and  sugar 
intake,  and  the  administration  to  the  mother  of  an  occasional  saline. 
This  stool,  more  than  any  other,  is  responsible  indirectly  for  the  high 
infant  mortality  during  the  first  year,  as  when  it  appears  it  is  regarded 
as  a  cause  for  commencing  artificial  feeding,  and  from  this  time  the 
course  of  many  infants  is  downward. 


HOW    TO    DRY    UP    BREAST    MILK.  37 

exercise.     Order  a  daily  allowance  of  beer,  stout,  or  other 
malt  preparations. 

HOW  TO  INCREASE  THE  TOTAL  MILK  SUPPLY. 

The  total  quantity  of  milk  may  be  deficient.  The  first 
indication  is  to  control  psychic  disturbances.  Any  undue 
loss  of  blood  or  other  of  the  body  fluids  must  be  prevented 
or  stopped.  At  least  two  weeks'  rest  in  bed  after  confine- 
ment must  be  enjoined.  Following  this  the  mother  must 
secure  plenty  of  rest,  and  later  a  sufficient  amount  of  gentle 
exercise,  together  with  an  abundance  of  easily  digested 
food.  She  should  be  made  to  drink  freely  of  water,  weak 
tea,  and  milk.  These  should  be  used,  together  with 

Galactogogues,  of  which  cornmeal  soup  (Southworth's 
soup]  is  an  admirable  one.  Maltropon  will  also  increase  the 
total  quantity  of  milk.  One  tablespoonful  of  this  is  mixed 
with  a  glass  of  cold  milk  or  water  and  taken  three  times  a 
day.  Lutein  derived  from  the  corpus  luteum  of  the  hog  is 
said  to  give  good  results.  Placing  the  infant  regularly  to 
the  breast  is  an  excellent  means  of  stimulating  the  flow  of 
milk. 

If  the  supply  of  milk  be  excessive,  caking  must  be  pre- 
vented by  regular  feeding  intervals,  the  occasional  use  of 
the  breast  pump,  hand-milking,  gentle  massage  with  warm 
oil,  and  the  administration  of  gentle  laxatives,  a,s  cascara 
or  a  small  dose  of  Epsom  salts. 

HOW  TO  DRY  UP  BREAST  MILK. 

This  may  be  necessary  on  account  of  the  death  of  the 

infant,  the  appearance  of  some  contraindication  to  maternal 

feeding,  the  age  of  the  infant   (after   12  months)   or  the 

occurrence  of  some  acute  infectious  disease.     In  the  last 


38  BREAST   FEEDING. 

event,  if  the  infant  be  the  victim,  it  may  not  suckle  the 
breast,  but  the  milk  should  be  withdrawn  and  fed  from  a 
bottle.  This  will  materially  increase  its  chances  of  recovery. 
Practically  all  fluids  must  be  withdrawn  from  the  diet, 
including  particularly  water,  milk,  soups,  alcoholic  malt 
beverages,  coffee,  tea,  and  cocoa.  Only  a  minimum  of 
water  is  allowed.  A  daily  saline  must  be  administered. 
The  breasts  should  be  emptied  by  the  pump  or  by  manipula- 
tion, and  both  glands  should  be  entirely  covered  (excepting 
the  nipples)  with  belladonna  ointment.  Lint  compresses,  in 
which  holes  are  cut  for  the  nipples,  are  applied  and  the  whole 
covered  by  a  snug  figure-of-8  bandage  supporting  both 
breasts.  Should  the  organs  become  painful  within  a  few 
hours,  the  bandage  must  be  loosened  or  removed,  the 
glands  emptied  by  the  pump,  and  the  whole  dressing  re- 
applied.  A  little  milk  may  remain  for  months. 

METHOD  OF  FEEDING  INFANTS  AT  THE  BREAST. 

An  infant  should  be  placed  at  the  breast  immediately 
after  birth.  The  theory  that  this  aids  uterine  contraction 
seems  to  have  some  foundation  in  fact.  From  birth  up  to 
the  period  of  6  weeks  an  infant  should  be  fed  every  two 
hours  during  the  day  and  twice  during  the  night.  The  first 
feeding  should  'be  given  at  6  P.M.  and  the  last  at  8  P.M. 
The  feedings  during  the  night  should  be  given  at  12  mid- 
night and  at  4  A.M.  If  the  child  awakens  oftener,  a  little 
warm  sterile  water  may  be  administered.  To  insure  the 
cultivation  of  the  habit  of  regularity,  the  child,  if  sleeping, 
should  be  awakened  for  its  food  during  the  day.  Toward 
the  end  of  this  period  one  of  the  night  feedings  should  be 
omitted.  Each  feeding  should  not  occupy  more  than  fifteen 
or  twenty  minutes.  The  infant  must  not  be  permitted  to 


METHOD  OF  FEEDING  INFANTS  AT  BREAST.  39 


Fig.  15. — How  to  hold  an  infant  while  at  the  breast.  The  head 
and  back  are  supported  by  one  forearm,  and  hand  while  the  index- 
and  middle-  fingers  of  the  free  hand  control  the  flow  of  milk,  either 
hastening  it  by  a  stripping  motion  or  slowing  it  by  pressure. 


40  BREAST    FEEDING. 

sleep  with  the  nipple  in  its  mouth.  The  infant  must  be  held 
in  such  a  position  as  to  insure  its  comfort.  The  mother  sup- 
ports its  head  and  back  upon  her  right  arm  if  the  child  is 
nursing  the  right  breast,  and  with  the  fingers  of  the  left 
hand  controls  the  flow  of  milk  from  the  nipple  (Fig.  15). 
The  infant  nurses  the  breasts  alternately  at  successive 
feedings,  unless  there  be  a  scanty  supply  of  milk,  then  both 
breasts  are  nursed  at  each  feeding.  From  the  second  to 
the  fourth  month  the  breast  is  given  every  two  and  a.  half 
hours  with  only  one  nocturnal  feeding,  and  the  latter  grad- 
ually omitted.  From  the  fourth  to  the  ninth  month  the 
feeding  intervals  should  be  increased  to  three  and  a  half 
hours,  and  the  nocturnal  nourishment  is  entirely  omitted. 
From  this  period  up  to  12  months  food  is  given  every  four 
hours.  The  hours  and  intervals  of  feeding  are  indicated  in 
the  following  table: — 

FEEDING  SCHEME.  Nocturnal 

Age.  Feeding  interval.      Time  of  feeding.  feeding. 

1  to    6  wks.  2      hours          A>M-  6'  8'  I0  ,  Two. 

P.M.   12,  2,  4,  6,  8 

2  to    4  mons.  2^  hours          A>M'  6'  8>3°'  "  One. 

P.M.  1.30,  4,  6.30,  9 

4  to    8  mons.  3      hours          ££  ^  9^  ^  ^  None. 

8  to  10  mons.  3^  hours          A>M>  7>  IO-3°  None. 

10  to  12  mons.  4      hours          A>M-  7'  ll  None. 

P.M.  3,  7,  10 

A  healthy  infant,  after  receiving  its  nourishment, 
passes  into  a  sound  sleep.  After  the  child  has  had  its  meal 
it  should  not  be  carried  around  nor  shaken,  but  quietly  laid 
in  its  crib.  Otherwise  regnrgitation  of  food  will  occur. 
Under  special  conditions  the  feeding  interval  may,  even 
during  the  very  early  periods  of  life,  be  lengthened  to  three 
or  to  four  hours.  These  will  be  pointed  out  as  we  proceed. 


PLATE  V 


' 


Stool  of  dyspepsia.  Occurs  in  both  the  breast-fed  and  bottle-fed  baby. 
In  the  former  its  significance  can  often  be  disregarded,  if  the  weight 
remains  unimpaired,  or  the  mother's  diet  may  be  regulated  as  in  Plate 
IV.  In  the  bottle-fed,  institute  a  hunger  period  for  twenty-four  hours. 
Then  reduce  the  fat  and  the  sugar  in  the  formula,  and  at  the  same  time 
administer  the  protein  mechanically  and  chemically  modified.  (See 
text.) 


CONTRAINDICATIONS  TO  MATERNAL  FEEDING.       41 

CONTRAINDICATIONS  TO  MATERNAL  FEEDING. 

A  woman's  milk  may  be  insufficient  in  quantity  and  of 
poor  quality.  The  quality  may  be  good,  but  the  quantity 
may  be  small.  Any  or  all  of  these  conditions  may  con- 
stitute a  contraindication  against  maternal  feeding  if  they 
cannot  be  corrected  or  if  they  interfere  with  the  infant's 
nutrition.  Painful  fissures  may  cause  a  temporary  suspen- 
sion of  nursing.  Abscesses  of  the  breast  usually  contraindi- 
cate  breast  feeding,  as  do  painful  and  septic  conditions  of 
the  infant's  mouth.  Mothers  who  suffer  from,  epilepsy, 
nervous  exhaustion,  chorea,  idiocy,  profound  anemia,  tuber- 
culosis, the  acute  infectious  diseases,  syphilis  contracted 
after  delivery,  and  profuse  hemorrhage,  should  not  suckle 
their  young.  A  woman  who  has  become  pregnant  while 
nursing  her  infant  should  cease  doing  so,  as  the  strain  of 
supplying  nourishment  to  both  fetus  and  child,  besides  her- 
self, is  too  great.  Menstruation,  also,  is  regarded  by  some 
as  a  contraindication  to  breast  feeding.  This  is  altogether 
a  question  of  the  individual,  and,  if  the  child's  nutrition  and 
digestion  are  not  disturbed,  menstruation,  per  se,  should 
not  prevent  the  infant  from  nursing.  A  woman  suffering 
from  puerperal  eclampsia  or  Bright's  disease  should  not 
nurse  her  child.  Malignant  disease  contraindicates  maternal 
feeding.  The  breast  should  be  withdrawn,  temporarily, 
from  a  nursling  suffering  from  acute  alimentary  intoxica- 
tion. The  physician  should  hesitate  long  before  he  advises 
the  withdrawal  of  the  breast.  Each  case  is  a  law  unto<  itself 
and  must  be  decided  on  its  merits.  Tuberculosis  and 
chronic  valvular  disease,  with  broken  compensation,  prevent 
nursing. 

An  infant  born  of  a  syphilitic  mother  should  be  nursed 
by  that  mother  even  if  it  shows  no  external  evidences  of 


42  BREAST    FEEDING. 

syphilis.  It  cannot  be  infected,  not  on  account  of  immunity, 
but  because  the  child  probably  has  latent  syphilis,  as 
would  be  shown  by  a  positive  Wassermann  reaction  (Pro- 
f eta's  law).  So,  too,  a  woman  apparently  free  of  syphilis 
should  nurse  her  babe  if  it  be  markedly  infected.  She  will 
not  become  infected  (Golles's  law).  The  reason  of  this  is 
because  she,  too,  has  latent  syphilis,  as  shown  by  a  posi- 
tive Wassermann  reaction.  Thus  a  scientific  explanation 
for  both  these  laws  is  available.  In  the  first  instance,  if  she 
contracts  syphilis  after  the  birth  of  her  babe,  nursing  must 
necessarily  be  discontinued.  The  susceptibility  of  the  infant 
under  such  circumstances  is  apparent. 

HYGIENE  OF  THE  NURSING  MOTHER. 

Many  women  who  object  to  nursing  do  so  from  the 
belief  that  they  thereby  surrender  themselves  for  a  period 
of  twelve  months  to  a  lonely  existence,  devoid  of  all  pleas- 
ure and  social  intercourse.  This  is  an  erroneous  idea,  and 
it  becomes  the  physician's  duty  to  make  plain  to  the  mother 
her  obligation  to  her  child.  From  the  day  of  conception,  or 
from  the  time  she  comes  under  her  medical  advisor's  care, 
every  prospective  mother  should  have  inculcated  within  her 
a  desire  to  nurse  her  infant.  Mother-love,  often  absent 
during  the  first  period  of  gestation,  gradually  develops  in 
most  women  as  the  day  of  labor  draws  near.  To  this  the 
physician  should  appeal,  and  make  known  to  his  patient  the 
dangers  and  vicissitudes  of  artificial  feeding  even  at  its 
best. 

Many  women  resort  to  bottle  feeding  through  igno- 
rance, or  through  the  enticing  advertisements  to;  be  found 
in  medical  journals  and  upon  the  labels  of  proprietary  foods. 
These  make  infant  feeding  an  easy  matter,  setting  at  naught 


HYGIENE    OF   THE    NURSING   MOTHER.  43 

the  work  of  some  of  the  best  minds  of  the  profession;  and 
the  eager  mother,  in  her  zeal  to  raise  her  infant  with  the 
least  care,  discovers  her  mistake  when  it  is  too  late,  when 
her  child,  with  a  fatal  pneumonia,  or  a  mortal  attack  of 
summer  diarrhea,  or  other  acute  infectious  disease,  suc- 
cumbs because  it  did  not  have  the  vital  force  to  resist  the 
disease — because  it  was  not  breast-fed!  The  physician 
should,  therefore,  preach  the  gospel  of  maternal  nursing 
day  in  and  day  out.  By  doing  so,  he  not  only  fulfills  his 
duty  to  his  patient,  and  stands  as  the  defender  of  helpless 
infancy,  but  renders  invaluable  service  to  his  State.  By 
doing  less  he  fails  in  the  fulfillment  of  his  mission. 

Between  the  nursing  periods  the  mother  should  spend 
her  leisure  in  useful  and  healthful  recreation.  She  should 
indulge  regularly  in  gentle  outdoor  exercise.  Reading  and 
participation  in  any  desirable  pastime  should  be  en- 
couraged. Rest  is  essential  to  her  well-being,  and  mental 
excitement,  fear,  and  worry  are  to  be  avoided.  She  should 
partake  freely  of  easily  digestible  and  nutritious  foods,  and, 
if  accustomed  to  a  glass  of  beer  or  light  wine  with  her  mid- 
day meal,  this  should  be  permitted.  Intemperance,  how- 
ever, in  all  things  must  be  interdicted.  Daily  bathing  and 
a  perfect  digestion  are  conducive  to  a  sufficient  and  nutri- 
tious supply  of  milk. 

Care  should  be  exercised  in  administering  drugs  to  the 
nursing  woman.  Certain  medicines  are  eliminated  in  the 
milk,  and  exert  their  physiologic  effect  upon  the  infant. 
Therefore  such  drugs  as  the  saline  purgatives,  morphin, 
colchicum,  belladonna,  arsenic,  antimony,  mercury,  and  the 
iodids  should  be  administered  cautiously,  if  at  all,  to  the 
lactating  mother.  The  care  of  the  nipple,  as  indicated  else- 
where, should  also  engage  the  attention  of  the  physician. 


44  BREAST    FEEDING. 

BREAST  FEEDING  DURING  ILLNESS  OF  MOTHER 
OR  CHILD. 

Whether  or  not  breast  feeding  is  to  be  continued  under 
these  circumstances  is  largely  a  problem  that  must  be  de- 
cided upon  the  merits  of  the  individual  case.  The  attitude 
of  the  physician,  however,  had  best  be  conservative  in  most 
instances.  Undue  haste  by  needlessly  sacrificing  the  milk- 
supply  and  hazarding  the  health  and  life  of  the  infant  may 
lead  to  disaster.  Reference  is  here  made  especially  to  the 
beginning  of  an  acute  illness  in  the  mother,  in  which  the 
milk,  as  a  rule,  should  not  be  withdrawn  until  the  diagnosis 
has  been  made,  or  if  an  acute  infectious  disease  be  reason- 
ably anticipated.  The  child's  safety  then  demands  imme- 
diate removal.  The  maternal  illness  may  last  but  a  day  or 
two,  and  keen  disappointment  will  follow  hurried  advice  to 
feed  the  baby  otherwise  than  by  the  breast.  If  it  be  advis- 
able— for  instance,  if  a  surgical  operation  of  minor  impor- 
tance must  be  performed — to  withhold  maternal  milk  for 
twenty-four  or  forty-eight  hours,  then  the  infant  may  be 
placed  upon  a  weak  milk  mixture  or  condensed  milk.  After 
a  day  or  two  it  is  an  easy  matter  to  rehabilitate  the  flow  by 
the  administration  of  fluids,  cornmeal  soup,  and  Maltropon. 
It  is  especially  in  cases  of  this  type,  and  in  the  harmless 
digestive  disturbances  of  the  breast-fed,  that  the  physician 
can  rise  above  the  ordinary  level  by  recognizing  and  meet- 
ing his  opportunity  for  conserving  the  maternal  milk- 
supply,  while  his  colleagues  of  less  discernment  will 
thoughtlessly  sacrifice  it. 

Illness  in  the  infant  is  rarely  a  cause  for  stopping  the 
breast.  Septic  conditions  of  the  mouth  and  throat,  or  an 
acute  infectious  disease  may  be  a  good  cause  to  remove  the 


WET-NURSING.  45 

infant  from  the  breast,  but  not  from  the  breast  milk.     It 
should  be  pumped  out  and  fed  by  the  bottle  or  dropper. 

WET-NURSING. 

Xext  to  maternal  feeding,  the  milk  of  a  healthy  wet- 
nurse  is  undoubtedly  the  safest  food  for  an  infant  under 
i  year  of  age.  The  selection  of  a  wet-nurse  should  be  left 
to  the  medical  attendant,  who  must  subject  her  to  a  rigid 
physical  examination  before  she  is  accepted.  Her  family 
history  should  be  carefully  scrutinized  and  her  past  and 
present  medical  history  examined.  A  woman,  the  off- 
spring of  tuberculous,  syphilitic,  or  cancerous  parents,  must 
be  rejected.  Her  health  should  be  perfect.  She  should 
have  sound  teeth,  normal  mucous  membranes,  good  diges- 
tion, healthy  lungs,  and  a  sound  heart  and  normal  kidneys. 
Her  skin  must  be  free  of  all  suspicious  rashes,  and  her 
venereal  and  child-bearing  history  carefully  examined.  A 
Wassermann  test  must  be  performed  on  every  applicant 
for  the  position  of  wet-nurse.  If  she  has  frequently  aborted, 
or  has  given  birth  to  many  stillborn  children,  she  should  be 
rejected.  Her  milk  should  be  analyzed  'in  order  to  estab- 
lish its  nutrient  qualities.  This  is  not  always  necessary,  as 
the  health  of  her  own  infant  will  usually  give  sufficient  in- 
formation as  to  the  quality  of  her  milk.  Her  breasts  should 
be  normal  and  well  developed,  free  from  rhagades,  ulcers, 
and  malignant  disease. 

A  nurse  who  is  suffering  from  any  form  of  infectious 
or  suppurative  disease,  however  slight  it  may  be,  should 
not  be  engaged.  The  same  applies  to  one  who  is 
irritable,  nervous,  epileptic,  or  choreic.  She  should  have 
a  just  appreciation  of  her  duty  and  a  sincere  love  for  chil- 
dren. She  need  not  be  especially  intelligent.  Probably  the 


46  BREAST    FEEDING. 

best  test  for  a  wet-nurse  is  the  condition  of  her  own  child, 
which  should  be  healthy  and  thriving.  If  possible,  other 
things  being  equal,  a  multipara  should  be  given  preference, 
although  a  primipara  need  not  be  rejected  for  this  fact 
alone.  As  a  rule,  however,  young  women  of  17  or  18  make 
poor  wet-nurses. 

In  the  family  who  has  engaged  her,  a  wet-nurse  oc- 
cupies a  peculiar  position.  If  a  good  nurse,  her  services  are 
often  invaluable,  a  fact  which  should  not  be  too  strongly 
impressed  upon  her  or  she  may  turn  tyrant.  She  should  be 
treated  with  kindness  and  courtesy,  be  well-housed,  well- 
fed  and  well-clothed,  in  addition  to  the  ordinary  compensa- 
tion which  she  receives.  The  same  care  should  be  accorded 
her  as  to  a  nursing  mother,  and  she  should  be  made  to  adopt 
the  same  hygienic  and  prophylactic  measures  which  pertain 
to  the  mother,  taking  sufficient  rest,  outdoor  exercise,  and 
diversion. 

Should  her  milk  disagree  with  the  infant,  either 
in  its  digestibility  or  in  its  capacity  to'  supply  sufficient 
nourishment,  as  evidenced  by  the  infant's  weight  and 
strength,  she  should  be  discharged  and  another  nurse  sub- 
stituted. A  syphilitic  baby  should  not  be  permitted  to  nurse 
a  healthy  wet-nurse.  Care  should  be  exercised  that  she  does 
not  slight  her  charge  by  giving  all  her  milk  to  her  own 
infant. 

Indications. — Wet-nursing  is  urgently  useful  in  the  care 
of  premature  infants,  in  cases  of  very  weak  infants  with 
whom  no  modification  of  cows'  milk  will  agree,  and  who 
are  threatened  with,  or  are  already  suffering  from,  inanition. 
Should  the  mother  die  suddenly  the  outlook  for  a  very 
young  though  healthy  infant  becomes  brighter,  as  the 
result  of  a  few  months  of  wet-nursing. 


WEANING.  47 

WEANING. 

By  weaning  is  meant  the  withdrawal  of  breast  milk  and 
the  use  of  stronger  food.  In  reference  to  babies  who  have 
been  reared  without  the  breast,  the  change  means  the  grad- 
ual cessation  of  bottle  feeding1  and  the  addition  of  solids 
to  the  diet.  Weaning,  to  be  done  successfully,  must  be 
done  gradually  in  most  cases.  In  others,  as  the  result  of 
the  death  of  the  mother,  failure  of  the  milk-supply,  maternal 
ill-health,  or  other  cause,  it  must  be  accomplished  rapidly. 
\Yith  wasted  infants,  who,  at  the  age  of  20  to  24  months 
writh  many  teeth,  are  still  at  the  breast,  no  time  should  be 
lost.  Ordinarily  weaning  should  take  place  between  the 
ages  of  10  months  and  12  months.  Some  practitioners  com- 
mence to  give  an  occasional  bottle  at  6  months.  This,  as  a 
general  practice,  is  unnecessary.  It  is  best  to  wean  after  the 
child  has  cut  several  teeth.  This  is  an  indication,  in  itself, 
that  the  gastrointestinal  glands  have  reached  a  more  ad- 
vanced stage  of  development,  and  are  capable  of  digesting 
stronger  food.  The  infant  should  not  be  weaned  while 
cutting  a  tooth.  It  should,  under  no  circumstances,  if  pos- 
sible, be  weaned  during  the  summer  months.  The  fall  and 
the  winter  are  the  best  times  of  the  year.  The  entire  time 
occupied  before  the  breast  is  finally  relinquished,  under 
ordinary  conditions,  is  about  two  to  four  weeks.  At  first 
one  breast  feeding  is  omitted  a  day  and  its  place  is  taken 
by  a  bottle,  the  composition  of  the  contained  milk  being 
similar  to  that  of  the  mother's  milk.  The  infant  is  kept  on 
this  for  three  or  four  days  or  a  week  before  another  change 
is  made.  At  this  time  another  bottle  feeding  is  substituted 
for  a  breast  feeding,  provided  the  digestive  organs  of  the 
child  have  not  been  deranged.  The  same  rule  is  followed 
and  no  change  is  made  for  another  few  days.  This  method 


48  •  BREAST   FEEDING. 

j 

is  continued  until  the  bottle  feedings  entirely  displace  the 
breast.  Now  follows  the  change  in  the  character  of  the 
milk  mixture  fed.  As  the  child  gains  in  weight  and  strength 
and  the  digestive  organs  remain  normal,  the  strength  of 
the  milk  mixture  is  gradually  increased  from  week  to'  week 
until  the  formula  corresponds  to  undiluted  cows'  milk.  At 
this  period,  about  the  age  of  12  to  14  months,  the  use  of 
the  bottle  is  gradually  discontinued,  and  the  milk  is  fed  by 
a  spoon  or  drunk  from  a  cup.  The  child  has  now  from  8  to 
14  teeth,  and  soft,  farinaceous  substances  are  gradually 
added.  Milk-toast,  well-cooked  rice,  oatmeal,  mashed  baked 
potatoes,  tapioca,  cream  of  wheat,  farina,  meat- juice,  the 
wing  of  a  spring  chicken,  baked  apple,  stewed  prunes,  soft- 
boiled  eggs,  and  egg-custard  are  some  of  the  substances 
which  may  slowly  be  added  to  the  diet  toward  the  close  of 
the  first  or  at  the  beginning  of  the  second  year.  The  meals 
are  gradually  reduced  to  three  a  day,  with  milk  or  some 
other  form  of  light  nourishment  given  between.  The 
fullest  meal  is  given  at  noon  and  the  lightest  at  6  P.M. 

After  dentition  is  complete,  other  substances  may  be 
carefully  added  and  the  child  be  permitted  to  sit  at  the  table 
with  the  family.  Such  articles,  however,  as  pastries,  candy, 
nuts,  pork,  veal,  rich  gravies,  fancy  dressings,  bananas, 
fresh  bread,  hot  cakes,  muffins,  turnips,  cabbage,  radishes, 
corn,  salt  and  smoked  fish  and  meats  are  to  be  carefully 
eliminated.  The  child  should  be  taught  to  chew  its  food 
slowly  and  well,  and  not  to  overeat.  By  watchful  care  and 
judicious  management  it  can  be  easily  taught  to  relish  those 
things  which  are  wholesome,  and  to  refuse  those  which  are 
indigestible.  The  diet  presented  in  Chapter  III,  page  140, 
may  now  be  used  to  great  advantage. 


CHAPTER  II. 
ARTIFICIAL  FEEDING. 


EXPLANATORY  AND  HISTORICAL. 

THE  textbook  presentation  of  this  subject  is  most  diffi- 
cult inasmuch  as  long  experience  is  of  immense  importance. 
Especially  is  this  so  at  the  present  time,  since  the  matter  is 
by  no  means  settled.  The  development  of  the  scientific 
artificial  feeding  of  infants,  up  to  within  a  few  years  ago, 
was  essentially  American.  Since  then  the  teachings  of  the 
German  school  of  pediatrists,  represented  by  Czerny,  Keller, 
Finkelstein,  Meyer,  Heubner,  Rubner,  Monti,  Escherich,  and 
others,  have  made  their  influence  felt  on  the  medical  mind. 

At  first,  analyses  of  human  milk  and  of  cows'  milk  were 
made  and  the  marked  quantitative  and  qualitative  differ- 
ences between  the  coagulable  protein  of  these  two  milks  were 
noted.  Under  the  initiative  of  Pepper  and  Meigs  in 
America  the  simple  diluting  of  cows'  milk,  so  that  the  vari- 
ous percentages  resembled  those  of  human  milk,  was  ad- 
vised and  practised.  To  this  diluted  milk  were  added  milk- 
sugar  and  cream  to  make  up  for  their  deficiency  incident 
to  the  dilution  of  the  cows'  milk.  These  mixtures  were 
soon  found  wanting  in  many  cases,  because  the  dilution  and 
additions  were  not  sufficient  to  overcome  certain  intrinsic 
biologic  and  physical  differences,  many  infants  failing  to 
thrive  upon  a  milk  which  nature  primarily  intended  for 
cows,  even  though  the  percentages  fed  accurately  equaled 
those  of  the  accepted  analyses  of  human  milk.  It  was 

4  (49) 


50  ARTIFICIAL   FEEDING. 

found,  for  instance,  that  a  child  could  digest  4  per  cent,  of 
fat  of  human  milk,  but  that  the  same  percentage  represented 
by  cow-fat  often  caused  disturbance.  This  fact  being  recog- 
nized, it  was  decided,  under  the  leadership  of  Rotch,  of  Bos- 
ton, that  the  basic  principle  was  to<  recognize  digestive  dis- 
turbances as  dependent  upon  the  fat,  protein,  or  sugar,  as  the 
case  may  be,  and  to  feed  to  the  infant  certain  definite  per- 
centages of  each  ingredient  and  to  increase  or  diminish 
them  at  will  according  to  the  indications.  From  this  was 
evolved  the  idea  of  the  laboratory  method,  or  the  percentage 
method,  or  the  American  system  of  infant  feeding.  From 
this  sprang  into  existence  the  Walker-Gordon  laboratory, 
which  sought  to  fill  the  physician's  prescription  for  any 
combination  of  percentages  which  he  might  desire.  This, 
however,  was  soon  found  to  be  impracticable  for  the  reason 
that  the  laboratories  were  confined  to  large  cities,  and  that 
the  cost  of  the  production  of  definite  percentage  mixtures 
was  beyond  the  means  of  the  poor,  who>  needed  it  most. 
The  idea  behind  the  percentage  method  seemed  to  be  a  good 
one,  i.e.,  to  feed  gradually  increasing  amounts  of  the  vari- 
ous ingredients  as  the  individual  case  required,  and  to 
increase  or  diminish  any  special  ingredient  as  the  indication 
arose. 

For  this  reason  the  so-called  home  modification  of  milk 
was  devised,  and  in  this  connection  the  work  of  Chapin, 
Holt,  Baner,  and  others  is  representative.  This  embraced 
the  so-called'  top  milk  and  the  milk-and-cream  mixture 
methods.  They  are  of  immense  practical  value  when  in- 
telligently applied,  and  serve  a  useful  purpose  in  the  evolu- 
tion of  scientific  feeding.  Many  physicians  seem,  however, 
to  be  unable  to  thoroughly  grasp  the  details  of  these 
methods,  and  experience  has  shown  that  as  good  results  can 


EXPLANATORY   AND   HISTORICAL.  51 

be  obtained  by  the  simple  dilution  of  whole  or  of  skimmed 
milk.  This  method  will  be  described  as  we  proceed. 

Later  it  developed  that  any  modification  which  failed  to 
recognize  the  physical  difference  between  the  calcium  para- 
casein  (curd)  of  human  and  that  of  cows'  milk  would  likely 
fail  unless  something  were  done  to  render  the  curdi  of  the 
latter  more  pregnable  to  the  digestive  juices  by  causing  it  to 
be  broken  up  into,  particles  resembling  the  coagulated  flocculi 
of  human  milk.  •  Jacobi  years  ago,  and  Chapin  more  re- 
cently, advocated  the  addition  of  cereal  decoctions  or  thin 
gruels  made  from  barley,  oatmeal,  rice,  etc.,  to  dilute  the 
milk  instead  of  plain  water.  Chapin  recommended  that 
these  cereal  waters  be  dextrinized.  Since  then  other  meth- 
ods of  dealing  with  the  coagulable  protein,  which  will  be 
described  later,  have  been  evolved.  Still,  in  spite  of  care- 
ful percentage  manipulation  and  the  attempted  adaptation 
of  the  milk  to  the  individual's  digestive  capacity,  failures 
were  numerous. 

It  now  came  to  pass  that  the  micro-organisms  were 
regarded  as  the  important  causes  of  mischief,  and  that  every 
percentage  formula  might  fail  unless  the  basis  of  it  was 
germ-free  milk.  From  this  arose  in  succession  the  advocacy 
of  sterilized,  pasteurized,  and  of  certified  milk.  Under  the 
impetus  given  by  Coit,  milk  commissions  exist  in  nearly  all 
the  large  cities  and  towns  of  America,  and  clean  milk 
(certified  milk)  is  regarded  as  an  essential  of  successful 
feeding. 

More  recently,  the  Germans  have  adopted  the  so-called 
caloric  method  of  feeding.  This  seeks  to  provide  a  suffi- 
ciency of  heat  units  as  required  by  the  weight  of  the  child. 
At  least  45  calories  for  every  pound  of  weight  are  regarded 
as  necessary.  The  Germans  ignore  the  percentage  composi- 


52  ARTIFICIAL   FEEDING. 

tion  of  the  mixture.  In  this  their  proposal  is  weak,  since 
it  fails  to  attempt  to  recognize  the  particular  ingredient 
which  may  be  at  fault  in  an  individual  case.  It  has  been 
well  said  that  the  number  of  calories  necessary  may  be  rep- 
resented by  a  ham  sandwich,  and  yet  the  infant  could  not 
digest  it.  The  German  school  also  denies  the  etiologic 
influence  of  the  curd  as  a  factor  in  indigestion,  and  of 
microorganisms  as  the  cause  of  summer  diarrhea.  They 
regard  the  fat  as  a  chief  offender,  the  protein  as  harmless, 
and  look  upon  the  fermentation  of  milk-sugar  as  the  chief 
cause  of  this  frequently  fatal  disorder  of  the  heated  season. 
While  the  German  idea  in  a  sense  simplifies  the  problem, 
many  of  their  claims  have  not  been  substantiated  clinically, 
at  least  in  America,  and  their  plan  of  feeding  can  be  made 
as  dogmatic  and  unindividual  as  it  is  claimed  that  the  per- 
centage method  of  feeding  is.  The  points  of  advantage  and 
of  disadvantage  will  be  emphasized  in  the  text  as  the 
problems  present  themselves. 

It  can  be  readily  realized  that 'the  subject  is  far  from 
settled,  that  no  textbook  outline  of  it  can  make  a  successful 
feeder  of  the  novice.  What  is  necessary  in  each  instance  is 
individualization  and  experience.  The  former  is  absolutely 
the  keynote  of  success.  "What  is  meat  for  one  is  poison 
for  another"  applies  nowhere  with  such  force  as  in  the 
artificial  feeding  of  infants.  In  the  following  presentation 
no  claim  is  made  to  originality.  Facts  will  be  stated  as  they 
have  been  learned  from  personal  clinical  observation  ob- 
tained in  an  extensive  hospital  experience  here  and  abroad, 
and  in  private  work  and  from  contact  with  eminent 
authority.  In  some  instances  it  may  be  necessary  to  plead 
guilty  of  being  ultra-conservative  and,  perhaps,  even  un- 
scientific. The  other's  right  to  his  view  is  recognized,  nor 


CHEMISTRY  AND  PHYSICS  OF  COWS'  MILK.  53 

is  it  denied  that  other  methods  are  productive  of  as  good 
results  in  the  hands  of  their  advocates.  Liberality  of  views, 
however,  and  the  elastic  interpretation  of  facts  and,  above 
all,  absolute  individualization  which  the  two  former  insure 
whatever  the  method  employed,  are  claimed  to  be  essentials, 
if  the  physician  would  become  a  successful  feeder. 

SUBSTITUTES  FOR  HUMAN  MILK. 
For  this  purpose  the  milk  of  lower  animals  has  been 
appropriated,  and  means  sought  to  adapt  it  to  human  needs. 
The  choice  of  animal  depends  considerably  upon  circum- 
stances and  the  environmental  influences  of  the  country. 
Almost  universally  cows'  milk  has  been  employed,  although 
use  has  also  been  made  of  the  milk  of  goats,  asses,  and 
mares.  Of  the  last  three,  the  first  alone  is  used  with  any 
great  frequency,  and  largely  in  rural  districts  and  among 
the  foreign  population.  The  composition  of  goats'  milk 

follows : — 

Jrer  cent. 

Fat    4-50 

Sugar    400 

Protein    4-50 

Mineral  matter   0.60 

Total  solids   13-60 

Water    86.40 

This  approaches  the  character  of  cows'  milk  and,  like  the 
latter,  is  deficient  in  sugar  and  richer  in  protein  than  human 
milk.  The  curd  is  finer  than  that  of  cows'  milk. 

CHEMISTRY  AND  PHYSICS  OF  COWS'  MILK. 

Like  human  milk,  the  composition  is  not  uniform.     It 

varies  in  the  same  cow  at  different  periods  of  the  milking, 

and  varies  in  the  different  udders.    Thus  the  composition  of 

the  milk  of  a  single  cow  might  differ  considerably  from  that 


54  ARTIFICIAL   FEEDING. 

of  an  entire  herd.  The  practical  uniformity  in  composition 
of  herd  milk  makes  it  more  preferable  for  general  purposes 
than  that  of  a  single  cow.  However,  the  danger  of  tuber- 
cular infection,  for  obvious  reasons,  is  less  from  the  milk 
of  a  single  cow,  properly  examined.  The  composition  also 
varies  with  the  type  of  cow.  Some  cows  are  better  adapted 
to  infant  feeding  than  others.  Thus  the  Jersey  and  the 
Guernsey  furnish  milk  rich  in  fat  (over  5  per  cent.)  and 
one  in  which  the  fat  emulsion  is  less  perfect  than  in  the 
milk  derived  from  a  Holstein-Friesian  or  the  Ayrshire. 
The  former  furnishes  milk  relatively  low  in  fat  (less  than 
3  per  cent.)  and  protein  as  well  (less  than  4  per  cent.). 
The  milk  from  the  latter  is  rich  in  protein  (over  4  per  cent.) 
and  weaker  in  fat  (slightly  under  4  per  cent.).  The  milk 
from  both  these  types  is  well  adapted  to  infant  feeding. 
The  Devon  and  Durham  cows  resemble  each  other  in  fur- 
nishing a  milk  of  good  average  richness. 

Cows'  milk,  like  human  milk,  is  an  opaque  emulsion  of 
fat  in  a  solution  of  albuminous  material,  lactose,  and  mineral 
matter.  The  color  is  white  or  yellowish  white.  The  odor 
is  said  to  be  characteristic,  and  is  also  determined  by  disease 
or  by  the  diet  of  the  cow.  Thus,  in  the  spring  of  the  year, 
the  odor  of  grass  or  garlic  is  common.  The  specific  gravity 
at  60°  F.  varies  from  1029  to  1034.  Its  oscillations  de- 
pend upon  the  composition  of  the  milk.  The  reaction  is 
amiphoteric,  leaning  toward  acid.  It  becomes  acid  a  few 
hours  after  milking,  the  acidity  increasing  with  age.  The 
addition  of  preservatives  increases  the  alkalinity. 

The  fat  of  cows'  milk  contains  olein,  stearin,  and  pal- 
mitin.  It  exists  in  considerable  proportion  as  volatile  fats 
which  are  readily  decomposed.  If  milk  be  allowed  to  stand, 


CHEMISTRY  AND  PHYSICS  OF  COWS'  MILK.  55 

the  fat  being  the  lightest  portion  of  it,  rises  to  the  surface 
and  is  known  as  cream. 

Cream,  therefore,  is  simply  superfatted  milk.  If  the 
cream  be  removed  by  skimming  after  it  has  risen  to  the 
surface  it  is  known  as  gravity  cream,  and  the  remaining 
portion  is  called  skimmed  milk.  Gravity  cream  varies  in 
strength,  depending  upon  the  length  of  time  permitted  for 
the  fat  to  rise  to  the  surface  and  the  depth  of  the  layer 
which  is  removed.  Thus,  if  a  quart  of  milk  be  allowed 
toi  stand  for  from  three  to  four  hours,  the  upper  n 
ounces  will  contain  approximately  10  per  cent,  of  fat,  while 
if  the  upper  16  ounces,  or  half  of  the  quart,  be  removed, 
this  superfatted  milk  or  cream  will  contain  about  7  per 
cent,  of  fat.  Cream  may  be  removed  by  the  centrifuge 
(centrifugal  cream}.  This  cream  is  much  richer,  contain- 
ing from  20  per  cent,  to  35  per  cent,  of  fat. 

The  amount  of  fat  in  whole  milk  is  not  constant.  Its 
variability  has  been  noted  in  the  different  breeds  of  cows. 
Good  milk  averages  about  4  per  cent.  The  range  of 
variability  allowed  by  most  milk  commissions  is  between 
3//2  per  cent,  and  4^  per  cent.  Microscopically  the  oil 
globules  of  the  fat  of  cows'  milk  are  seen  to  be  large 
(Fig.  7,  II).  The  caloric  value  of  the  fat  is  9. 

The  protein  exists  in  solution  as  calcium  casein  (for- 
merly caseinogen)  and  as  lactalbumin  and  lacto globulin. 
Other  protein  substances  of  less  importance  are  present,  but 
have  no  general  practical  interest.  If  cows'  milk  be  acted 
upon  by  rennin  or  by  the  gastric  juice  in  the  presence  of 
body  temperature  it  coagulates  into  a  solid  mass.  From 
this  mass  will  exude  a  perfectly  clear,  colorless  fluid,  and  the 
mass  will  contract  into  a  tough  curd.  The  colorless  fluid 
is  known  as  whey,  and  contains  principally  the  so-called 


56  ARTIFICIAL  FEEDING. 

whey-proteins  or  soluble  proteins — lactalbumin  and  lacto- 
globidm,  as  well  as  the  salts  of  milk  and  the  sugar  of  milk- 
lactose.  During  the  process  of  separating  from  the  curd 
some  little  fat  is  carried  along.  Although,  theoretically, 
whey  should  contain  no  fat,  practically  it  does.  The  com- 
position of  whey  is  variously  given  by  chemists.  An 

average  analysis  follows: — 

Per  cent. 

Protein    0.94 

Fat    0.96 

Lactose 549 

Salts    0.48 

Water1    92.13 


100.00 


Thus  it  may  practically  be  regarded  as  a  5  per  cent,  solu- 
tion of  milk-sugar  containing  I  per  cent,  of  whey-proteins 
and  i  per  cent,  of  fat. 

Lactalbumin  and  lactoglobulin  constitute  about  one-third 
or  one-fifth  of  the  total  protein.  The  former  resembles 
serum  albumin  and  the  latter  serum  globulin. 

The  coagulable  portion  of  the  protein  remaining  is 
known  as  the -curd,  or  calcium  paracasein  (formerly  casein), 
and  constitutes  the  large  part  of  the  albuminous  content 
(about  two-thirds  or  four-fifths).  When  coagulation 
occurs  the  curd,  which  is  tough,  leathery,  and  dense,  con- 
tains within  its  meshes  fat  globules,  some  lactose,  and 
mineral  salts.  The  amount  of  combined  protein,  as  the  fat, 
is  variable,  but  in  good  milk  it  averages  about  4^2  per  cent. 
A  variation  of  from  3  per  cent,  to  4  per  cent,  may  be 
regarded  as  within  the  normal  limits.  The  caloric  value  of 
the  combined  protein  is  4. 

Lactose  constitutes  the  main  carbohydrate.  It  is  a  di- 
saccharid.  It  is  readily  changed  to<  lactic  acid  by  the  lactic 


CHEMISTRY  AND  PHYSICS  OF  COWS'  MILK.  57 

acid  bacillus.  It  crystallizes  into  hard,  white  prisms.  It  is 
less  sweet  than  cane-sugar  (weight  for  weight)  and  is 
soluble  in  6  parts  of  cold  water.  It  is  not  fermented  by 
yeast.  It  reduces  Fehling's  solution.  When  acted  upon  by 
dilute  mineral  acids  it  is  changed  to  dextrose  and  galactose. 
The  lactose  of  commerce  is  obtained  as  a  by-product  in  the 
manufacture  of  cheese  by  the  evaporation  of  whey.  It  is 
identical  in  composition  to  the  lactose  of  human  milk,  but 
it  is  unclean  and  requires  sterilization.  Cows'  milk  contains 
about  4  per  cent,  of  lactose,  which  has  a  caloric  value  of  4. 

The  mineral  constituents  consist  principally  of  the 
phosphate  of  potassium,  sodium,  calcium,  and  magnesium, 
together  with  the  chlorids  of  potassium  and  sodium.  Iron 
is  found  in  less  quantity  than  in  human  milk.  It  is  in 
organic  combination  with  nuclein.  Milk  contains  about 
0.75  per  cent,  of  mineral  matter. 

Bacteria. —  Some  of  the  bacteria  found  in  milk  are  patho- 
genic and  others  are  not.  Of  the  former  the  more  common 
are  the  tubercle  bacillus,  the  bacillus  of  typhoid  fever,  and 
the  bacillus  of  diphtheria.  Epidemics  of  scarlet  fever  have 
not  infrequently  been  traced  to  a  contaminated  milk-supply. 
Local  disease  of  the  udder  may  cause  the  entrance  of  the 
different  varieties  of  streptococci,  staphylococci  and  more 
rarely  of  anthrax  bacilli.  The  commoner  non-pathogenic 
varieties  found  are  those  belonging  to  the  lactic  acid  and 
the  colon  groups.  The  total  solids,  including  fat,  protein, 
lactose,  mineral  constituents  and  bacteria,  average  about 
I3//2  per  cent.  The  remainder  is  water. 

'  The  microscopic  appearance  shows  the  fat  globules  toi  be 
large  and  floating  in  an  opaque  fluid.  Some  epithelium  and 
a  few  leucocytes  may  be  present  and  are  to  be  regarded 
as  normal  (Fig.  7,  II).  Any  increase  in  these  indicates 


58  ARTIFICIAL   FEEDING. 

disease,  usually  inflammation  of  the  udder,  and  renders  the 
milk  unfit  for  food.  Bacteria  are  readily  recognized  by 
staining,  or  they  may  be  seen  in  the  fresh  specimen.  For 
positive  identification  they  must  be  cultured,  colonized, 
isolated,  and  stained. 

Sources  of  Adulteration  and  Contamination. —  Milk  oc- 
cupies the  dual  position  of  being  the  bottle  babies'  best  friend 
and  worst  enemy.  The  latter  is  brought  about  by  con- 
tamination and  adulterations,  either  accidental  or  intentional. 
The  initial  source  of  contamination  occurs  at  the  time  of 
milking,  and  one  of  the  most  important  is  the  dust-laden 
air  of  the  stable.  Anyone  who  has  ever  visited  a  farm  and 
watched  the  ordinary  farmer  milk  his  cows  and  then,  when 
through,  to  see  him  strain  it  through  a  coarse  strainer  and 
then  note  that  left  in  the  latter  are  particles  of  straw, 
manure,  dust,  and  hair,  will  be  able  to>  appreciate  how 
readily  milk  may  become  a  carrier  of  disease. 

The  cows  are  usually  kept  in  poorly  ventilated  stables, 
in  stalls  provided  only  with  straw  beds,  and  with  no  means 
of  collecting  the  manure,  which  becoming  entangled  in  the 
straw  and,  drying,  is  thrown  into  the  air,  by  the  kicking  and 
shuffling  of  the  animal.  Flies  are  not  excluded,  and  the 
udder  too  is  covered  with  dry  manure  and  milk.  The 
farmer  does  his  milking  into  an  open,  perhaps  unwashed, 
bucket  or  one  rinsed  in  spring-water.  The  atmosphere  is 
dust-laden  and  his  hands  are  probably  unclean.  The  cow 
may  have  an  ulcerated,  inflamed,  or  even  tubercular  udder. 
From  his  bucket  the  milk'  is  placed  into  an  indifferently 
cleansed  can,  after  straining  as  indicated — the  gross  par- 
ticles having  been  removed,  but  the  micro-organisms  all 
passing  through.  The  cans  are  placed  in  the  spring-house, 
in  which  the  temperature,  while  low,  is  not  sufficiently  so  to 


CHEMISTRY  AND  PHYSICS  OF  COWS'  MILK.  59 

prevent  bacterial  growth.  Before  being  placed  in  the  cans,- 
if  the  farmer  be  unscrupulous,  the  milk  may  be  watered  or 
preservatives  introduced,  or  chalk  added  to  whiten  it.  It 
is  now  transported  to  the  railway  station,  where  it  awaits 
the  early  train.  In  the  mean  time  bacterial  growth  can  con- 
tinue. It  reaches  the  city,  where,  on  the  unloading  plat- 
form, it  may  be  exposed  to  the  sun  for  hours.  This  again 
favors  the  further  development  of  micro-organisms.  Ex- 
posure again  occurs  in  the  milk-house  where  it  must  be 
bottled,  and,  unless  the  establishment  is  run  in  a  hygienic 
manner,  the  improperly  washed  bottles  and  the  hands  of  the 
workmen  may  be  a  further  source  of  contamination.  In  the 
early  morning  it  is  delivered  on  the  doorstep  of  the  consumer, 
where  it  remains  exposed  for  a  few  hours  to  a  gradually 
rising  temperature,  and  in  summer  months  to  a  very  high 
degree  of  heat. 

In  the  home  the  soiurces  of  additional  infection  are 
many.  Danger  may  arise  from  improper  icing,  improperly 
sterilized  receptacles,  bottles,  nipples,  and  the  water  used 
to  dilute  may  be  unfit  for  this  purpose.  The  formula,  even 
if  properly  made,  may  not  be  carefully  iced,  and  bacterial 
growth  continues  uninterrupted.  In  some  cases  the  milk  is 
not  bottled,  but  sold  direct  to  grocery  stores  and  thence  to 
the  consumer,  being  clipped  from  the  can  into  a  pitcher. 
Infection  readily  occurs  in  this  manner.  Milkmen  have 
been  seen  to  drink  milk  from  the  lid  of  the  can  while  en 
route  in  the  city  streets,  and  to  return  what  they  did  not 
want  to  the  can.  This,  not  alone  filthy  habit,  is  exception- 
ally dangerous  in  that  the  likelihood  of  tubercular  contami- 
nation is  imminent.  Another  unclean  habit  is  for  the 
mother  or  nurse  to  suck  the  milk  from  the  nursing  bottle 
in  testing  the  temperature  before  feeding  it  to  the  baby. 


60  ARTIFICIAL   FEEDING. 

It  is  readily  seen,  therefore,  that  from  the  time  the  milk 
leaves  the  cow  until  it  reaches  the  consumer  it  is  exposed  to 
many  and  varied  sources  of  infection. 

Analysis  of  Milk  and  Detection  of  Chemical  Adulter- 
ation.— Analyses  for  the  various  normal  constituents  of 
cows'  milk  are  conducted  as  for  human  milk  (Chapter  I). 
The  average  corn-position  of  normal  milk  may  be  stated  as 

follows : — 

REACTION,  AMPHOTERIC  OR  ACID. 

Specific  gravity 1029  to  1034 

Protein 3-5o%  to    4.50% 

Fat    4.00% 

Water    4.00% 

Mineral  matter   75% 

Total  solids 12.25%  to  13.25% 

Water    87.75%  to  86.75% 

Watering  of  Milk. — Water  is  added  to<  milk  by  dis- 
honest dairymen  and  dealers,  to  increase  the  volume.  Aside 
from  the  moral  aspect  of  the  procedure,  this  is  a  very 
dangerous  practice.  It  dilutes  the  various  chemical  con- 
stituents, thereby  destroying  the  nutritive  qualities  of  the 
milk.  Besides  it  adds  to  the  milk  millions  of  micro- 
organisms, many  of  which  may  be  pathogenic.  In  the  same 
class  belong  those  cases  where  skimmed  milk  is  sold  for 
pure  cows'  milk.  An  easy  and  simple  method  of  detecting 
these  practices,  aside  from  noting  the  physical  character  of 
the  milk,  is  by  the  use  of  a  small  hydrometer.  Skimmed 
milk,  when  allowed  to  stand,  will  collect  no  cream  on  the 
surface.  It  is  paler  than  pure  milk  and  has  a  higher  specific 
gravity,  because  the  cream,  the  lightest  constituent,  has 
been  removed.  Watered  milk  is  pale  bluish  in  color  and  of 
a  low  specific  gravity.  Milk  may  be  both  skimmed  and 
watered  at  the  same  time,  exhibiting  a  normal  specific 
gravity.  These  adulterations  can  usually  be  detected  with 


CHEMISTRY  AXD  PHYSICS  OF  COWS'  MILK.  61 

the  naked  eye  or  are  discovered  by  chemical  analysis.  For 
practical  purposes  the  lactometer  (ordinary  hydrometer) 
is  very  convenient,  and  is  a  rapid  means  of  detecting  a  good 
from  a  bad  milk  (Fig.  9,  page  19). 

Preservatives. —  Preservatives  are  added  to  milk  to  keep 
it  fresh,  to  prevent  the  growth  of  micro-organisms,  and  to 
save,  to  the  dealer,  the  expense  of  extensive  icing.  Among 
the  preservatives,  formaldehyd  is  the  most  extensively  em- 
ployed. Boric  acid,  benzoate  of  soda,  borax,  bichromate  of 
potassium,  and  salicylic  acid  are  used,  but  to  a  much  less 
extent.  Chalk  is  added  at  times,  to  color  the  milk  white 
after  it  has  been  watered. 

Formaldehyd  is  usually  employed  in  the  form  of  for- 
malin, which  is  a  40  per  cent,  solution  of  formaldehyd  gas 
in  water.  Only  a  few  drops  of  this  solution  need  be  added 
to  a  pint  of  milk  to  keep  it  sweet.  Formalin  is  rarely  added 
in  sufficient  quantity  to  be  tasted.  It  may  be  detected  by 
two  principal  tests :  (a)  Dilute  a  small  quantity  of  milk  with 
an  equal  amount  of  water.  Pour  this  gently  upon  some 
strong  sulphuric  acid  in  a  test  tube.  If  formaldehyd  be 
present,  there  will  appear  a  violet  color  at  the  line  of  con- 
tact. If  formaldehyd  be  absent,  a  greenish  or  brownish  ring 
will  be  formed.  Hydrochloric  acid  causes  the  casein  of 
milk  to  appear  yellow  in  the  presence  of  formaldehyd. 

(b)  Distil  a  small  quantity  of  milk  and  to>  the  distillate 
add  a  drop  of  a  weak  solution  of  carbolic  acid  in  water. 
Gently  pour  this  over  some  strong  sulphuric  acid.  If  for- 
maldehyd be  present  a  red  ring  is  formed  at  the  line  of 
contact. 

Borax  and  boric  acid  are  detected,  qualitatively,  in  the 
following  manner:  (a)  A  small  quantity  of  milk  is  diluted 
with  an  equal  amount  of  distilled  water,  and  then  slowly 


62  ARTIFICIAL  FEEDING. 

evaporated  to  dryness.  The  residue  is  shaken  with  alcohol 
and  filtered.  The  filtrate  is  then  ignited  and  burns  with  a 
green  flame. 

(6)  If  a  piece  of  tumeric  paper  be  immersed  in  a 
solution  containing  boric  acid,  upon  drying  it  turns  to  a 
reddish-brown  color. 

To  detect  salicylic  acid  mix  a  small  amount  of  the  sus- 
pected milk  with  an  equal  quantity  of  water.  Add  a  few 
drops  of  acetic  acid,  and  apply  ,  gentle  heat  to  the  boiling 
point,  but  do  not  boil.  Add  an  excess  of  pure  mercuric 
nitrate.  The  casein  is  coagulated.  Filter.  Evaporate  the 
filtrate.  Agitate  the  residue  with  ether.  Evaporate  the 
ethereal  extract.  Touch  the  residue  with  a  few  drops  of 
tincture  of  ferric  chloride.  If  salicylic  acid  be  present  there 
occurs  a  violet  color. 

Potassium  bichromate  may  be  detected  by  coagulating 
the  milk  with  a  few  drops  of  acetic  acid  and  gentle  heat. 
Filter.  To  the  filtrate  add  a  few  drops  of  a  solution  of 
lead  acetate.  A  yellow  precipitate  of  lead  chromate  indi- 
cates the  presence  of  the  preservative. 

Milk  containing  chalk  is  alkaline  in  reaction  and  effer- 
vesces upon  the  addition  of  hydrochloric  acid,  setting  free 
carbon  dioxid  gas.  The  crystals  of  calcium  carbonate  may 
be  detected  by  the  microscope. 

Hygienic  Care  of  Cows. — While  not  attempting  to  deal 
with  this  subject  in  the  comprehensive  manner  which  it 
merits,  a  work  of  this  kind  that  failed  to  emphasize  the 
great  importance  of  it  would  be  incomplete.  All  cows 
should  be  tested  with  tuberculin  and  mallein.  The  cow- 
barns  must  be  made  sanitary.  The  stalls  must  be  kept 
clean  and  free  of  all  dust  and  manure.  The  food  must  be 
selected  and  clean  and  regularly  given  to  prevent  indiges- 


CHEMISTRY  AND  PHYSICS  OF  COWS'  MILK.  63 

tion.  The  animals  should  be  regularly  watered.  The 
udders  are  to  be  kept  clean,  especially  before  milking, 
which  should  be  done  in  a  separate  dust-free  room.  Plenty 
of  rest,  and  exercise  in  the  green  pasture  are  essential. 
Under  no  circumstances  should  the  cows  be  frightened  or 
teased.  In  winter  they  are  to  be  housed  in  such  a  manner 
that  they  do  not  suffer  from  cold. 

Collection  and  Care  of  Milk  for  Marketing. — Cows  must 
all  be  free  from  tuberculosis  and  glanders.  The  cow-stable 
should  be  well  ventilated.  The  floors  should  be  boarded. 
The  cows  should  be  curried  and  groomed  daily.  The  fecal 
and  urinary  discharges  should  be  removed  from  the  stall 
at  once.  Attendants  should  be  free  of  disease,  and  scrupu- 
lously clean  in  person  and  of  good  disposition.  Persons 
who  have  just  recovered  from  typhoid  fever  should  not  be 
employed.  Privies  and  urinals  receiving  human  excrement 
must  be  far  removed  from  the  cows  or  the  milk-room.  If 
possible  the  milking  should  be  done  in  a  separate  compart- 
ment, into  which  the  cow  is  taken  after  the  udder  has  been 
thoroughly  cleansed  with  soap  and  water,  rinsed  and  dried. 
The  milker's  hands  are  prepared  by  thorough  scrubbing  and 
immersion  into  an  antiseptic  solution.  The  milking  is  done 
into  the  spout  of  a  covered  can  upon  which  the  milker  sits 
(Fig.  1 6).  In  the  spout  is  a  metal  filter.  Previous  to  use, 
the  can,  and  especially  the  filter,  should  be  scrubbed  with 
soap  and  water,  rinsed,  and  scalded  with  live  steam.  The 
milk  is  at  once  carried  into  the  cooling  room,  where  it  is 
placed  into  a  special,  previously  sterilized  cooling  apparatus, 
which  permits  it  to  flow  into  sterilized  quart  bottles.  The 
bottles  are  closed  with  sterile  caps  and  at  once  iced.  The 
milk  has  not  been  touched  by  human  hands  and  has  reached 
a  refrigerating  temperature  within  half  an  hour  after  leav- 


64  ARTIFICIAL  FEEDING. 

ing  the  cow's  body.  It  is  shipped  to  the  city  iced  and  kept 
so  until  it  readies  the  door  of  the  consumer.  This  it  should 
do  in  not  less  than  twenty-four  hours.  It  may  even  be 
delivered  iced  in  small  individual  boxes. 

Care  of  the  Milk  in  the  Home.— On  the  doorstep  of  the 
consumer  great  damage  may  often  be  done  to  the  very 
cleanest  milk.  What  organisms  have  entered  at  the  time  of 
milking  may  rapidly  increase  if  the  bottle  be  permitted  to 
remain  long  exposed  to  the  sun.  It  should  be  immediately 


Fig.  16. — Proper  can  used  in  milking  cows.     (Dairyman's 
Supply  Co.,  Philadelphia,  Pa.) 

taken  into  the  house  and  iced  until  needed.  When  making 
modifications  every  possible  means  of  cleanliness  and 
sterilization  with  reference  to  apparatus  and  diluents  should 
be  carefully  managed,  otherwise  a  perfect  milk  may  be- 
come contaminated.  After  the  formula  has  been  made,  care- 
ful and  continuous  icing  are  essential.  In  other  words,  the 
requirements  necessary  to  secure  a  good  milk,  aside  from 
its  proper  hygienic  care  in  the  home,  are  perfect  dairy 
hygiene  and  healthy  cows,  quick  refrigeration  and  ship- 
ment to  the  city,  or,  as  someone  has  said,  it  is  important 
to  "shorten  the  time  between  the  cow  and  the  baby." 


PLATE  VI 


Constipated,  greasy  stool  of  artificially  fed  infant.  This  stool  is  due 
to  the  administration  of  too  much  fat.  It  is  foul-smelling  (like  Lim- 
burger  cheese),  and  is  commonly  accompanied  by  a  stationary  weight 
and  an  ammoniacal  urine.  Reduce  or  omit  the  fat  in  the  formula  or 
practice  the  other  methods  for  treating  fat  intolerance.  (See  text.) 


ORDINARY,  NURSERY,  AND  CERTIFIED  MILKS.         65 

Clean  milk  is  an  essential  to  successful  infant  feeding,  and 
it  matters  not  how  well  may  be  adjusted  the  percentage  or 
caloric  requirements  of  the  food,  it  will  not  only  fail  in  its 
purpose,  but  it  will  accomplish  serious  damage  as  well, 
unless  this  is  actually  secured. 

Consumable  milk  as  marketed  today  may  be  readily 
classified  under  three  types : — 

ORDINARY  MILK,  NURSERY  MILK,  AND 
CERTIFIED  MILK. 

Ordinary  Milk. — This  is  milk  that  is  sold  from  cans  in 
the  shops,  or  from  wagons,  or  may  be  bottled  at  the  city 
distributing  station  after  shipment  in  large  cans.  It  is  con- 
stantly exposed  to  contamination  and  is  scarcely  a  fit  food 
for  infants.  The  bacterial  count  is  high.  It  should  never 
be  given  unboiled.  It  sells  for  8  cents  a  quart  in 
Philadelphia. 

Nursery  Milk,  so  called,  represents  an  attempt  to  pro- 
duce a  higher  grade  or  cleaner  milk.  \t  is  bottled  on  the 
farm  and  usually  contains  a  smaller  number  of  bacteria  than 
ordinary  milk.  It  should  never  be  fed  unpasteurized  or  un- 
sterilized.  It  costs  about  12  cents  a  quart. 

Certified  Milk  represents  an  attempt  at  the  production  of 
a  perfectly  clean  milk.  Coit,  of  Newark,  was  the  first  to 
conceive  the  idea  of  a  milk  commission  in  conjunction  with 
the  County  Medical  Society,  or  independent  of  it.  The 
milk  commission  has  in  its  employ  a  chemist  and  a  bac- 
teriologist whose  duties  are  to  visit  the  dairy  of  anyone 
who  may  enter  into  an  agreement  with  the  commission.  At 
stated,  but  unannounced,  intervals  the  chemist  and  bac- 
teriologist inspect  the  dairy  and  examine  the  milk.  If  it  be 
up  to  the  standard  as  decided  upon  by  the  milk  commission, 


66  ARTIFICIAL  FEEDING. 

the  dairyman  receives  a  certificate — hence  certified  milk, 
which  simply  means  the  purest  and  most  wholesome  milk 
obtainable.  If  the  requirements  are  not  met  the  certificate 
is  withheld,  after  giving  the  dairyman  ten  days  in  which 
to  correct  the  error.  The  milk  commission  requires  perfect 
dairy  hygiene  and  demands  a  certain  bacterial  standard. 
This  has  not  been  uniform  with  all  commissions,  some 
allowing  10,000  bacterial  colonies1  and  some  20,000  or  more 
per  cubic  centimeter.  The  American  Association  of  Medical 
Milk  Coimmissioiiers  has  adopted  10,000  as  the  maximum 
number  allowed.  As  far  as  possible  the  nature  of  these 
organisms  should  be  determined,  as  the  presence  of  a  few 
pathologic  ones  (typhoid  fever,  for  example)  would  d)o 
more  damage  than  many  non-pathogenic  bacteria.  In  order 
to  keep  the  number  as  low  as  possible  the  milk  must  not  be 
over  30  hours  old  before  it  is  received  by  the  consumer. 

Besides  the  bacteriologic  requirements,  the  milk  must 
contain  not  less  than  3^/2  per  cent.  o>f  fat  and  preferably  4^ 
per  cent.;  cream  not  less  than  18  per  cent.  From  3  per 
cent,  to  4  per  cent,  of  protein  must  be  present.  There 
must  be  no  preservatives,  and  the  specific  gravity  is  re- 
quired to  be  between  1029  and  1034. 

The  commission  also  supervises  the  health  of  the 
employes. 

It  will  be  seen,  therefore,  that  the  cost  of  production  of 
certified  milk  is  greater  than  under  ordinary  circumstances. 
For  this  reason  this  milk  sells  from  16  to  24  cents  a  quart. 

"May  certified  milk  be  fed  raw?"  is  a  common  query. 

1  The  terms  "bacteria"  and  "bacterial  colonies"  are  commonly  used 
interchangeably.  This  is  an  error,  as  the  colonies  are  counted  and  not 
the  bacteria.  This  distinction  is  important,  as  it  can  be  readily  ap- 
preciated that  there  is  quite  a  difference  between  10,000  bacteria  and 
10,000  bacterial  colonies. 


HOW  COWS'  MILK  DIFFERS  FROM  MATERNAL.         67 

Theoretically  it  should  be  perfectly  safe  and  is  so  during 
eight  months  of  the  year.  During  June,  July,  August,  and 
September,  in  order  to  make  assurance  more  certain,  it  is 
recommended  that  even  certified  milk  should  be  pasteurized 
or  sterilized  in  the  home. 

HOW  COWS'  MILK  DIFFERS  FROM  MATERNAL  MILK. 

The  proper  adaptation  of  cows'  milk  entails  a  knowl- 
edge of  the  biologic,  chemical,  and  physical  differences  be- 
tween it  and  human  milk. 

The  reaction  of  cows'  milk  to  litmus-paper  is  amphoteric 
or  acid.  By  the  time  it  reaches  the  consumer  it  is  acid, 
owing  to  the  formation  of  lactic  acid.  That  of  human  milk 
is  amphoteric,  leaning  toward  alkaline.  The  specific  gravity 
of  cows'  milk  is  1029  to  1034,  that  of  human  milk  1031. 
The  greatest  difference  between  these  two  milks  is  in  the 
character  and  the  quantity  of  the  protein.  When  cows'  milk 
is  acted  upon  by  rennin  or  pepsin,  at  body  temperature,  the 
coagulable  portion  (calcium  paracasein)  derived  from  cal- 
cium casein  (caseinogen)  clots  in  large,  lumpy,  tough 
curds.  The  liquid  portion  contains  lactalbumin  and  lacto- 
globulin.  It  has  been  shown  that  the  calcium  casein,  of 
human  milk  is  changed  by  rennin  into  fine,  flaky  curds  of 
calcium  paracasein.  The  amount  of  combined  protein 
found  in  cows'  milk  equals  about  4.5  per  cent.,  two-thirds 
of  which  is  coagulable  by  rennin.  The  total  amount  in 
human  milk  is  1.5  per  cent.,  of  which  but  one-fourth  is 
coagulable  by  rennin.  The  fats  existing  in  the  two  milks 
are  about  equal  in  amount,  but  those  of  cows'  milk  are  more 
volatile  and  irritating.  There  exists  in  cows'  milk  only 
about  one-half  as  much  lactose.  Cows'  milk  is  practically 
never  sterile.  It  may  be  sterile  in  the  cow's  udder,  but  as 


68  ARTIFICIAL   FEEDING. 

soon  as  it  strikes  the  air  or  the  surface  of  the  teat  it  be- 
comes contaminated.  It  also  receives  micro-organisms 
from  the  hands  of  the  milker,  sores  upon  the  udder,  the 
milk  cans  and,  sometimes,  from  the  water  which  is  added 
to  dilute  the  milk  by  dishonest  dealers.  The  organisms 
gain  entrance  into  the  milk  by  the  medium  of  flies,  stable 
dust,  and  manure.  They  may  be  pathogenic  or  non-patho- 
genic, depending  upon  their  source.  They  multiply  rapidly 
and  may,  equal  20,000,000  colonies  per  cubic  centimeter. 
They  constitute  a  dangerous  factor  when  cows'  milk  is  em- 
ployed as  an  infant  food,  playing  an  important  role  in  the 
production  of  the  summer  diarrheas  and  other  gastroin- 
testinal complaints.  The  following  table  shows  the  differ- 
ences detailed  above: — 

Cow's  MILK.  HUMAN  MILK. 

Amphoteric  or  acid Reaction Alkaline. 

1029  to  1034 Specific  gravity .1029  to  1031. 

4.5% Proteins 1.5   to   2%. 

Clots  in  large  lumpy  curds.  .Effect  of  rennin Clots  in  fine  curd. 

4.0  % Fats 3.50  to    4%. 

4.0  % Lactose 6.0    to    7%. 

0.75% Salts 0.20  to     i%. 

13.25% Total  solids 1 1.20  to  14%. 

86.75% Water 88.80  to  86%. 

Never  sterile Bacteria Practically  sterile. 

THEORY  OF  MILK  ADAPTATION. 
The  term  "milk  adaptation"  is  better  than  "milk 
modification"  for  the  reason  that  it  at  once  defines  the 
principle  upon  which  the  problem1  of  infant  feeding  and  of 
milk  manipulation  rests,  viz.,  individualization.  A  success- 
ful feeder  of  infants  must  individualize  and  not  feed  by  rule 
of  thumb.  The  importance  of  this  one's  or  that  one's 
method  of  feeding  is  fast  disappearing  in  so  far  as  it  would 
describe  a  fixed  way  of  feeding  all  infants.  As  a  means 


THEORY   OF    MILK   ADAPTATION.  69 

toward  an  end,  any  method  that  will  permit  of  the  manipu- 
lation of  milk,  so  that  it  will  fit  the  requirements  of  the  in- 
dividual infant,  will  live  and  continue  to  be  a  means  of 
considerable  help.  One  may  not  feed  an  infant  percentages 
of  fat,  protein,  and  lactose  suitable  to  its  age  on  calories 
said  to  be  required  by  its  weight,  but  one  must  feed  per- 
centages of  these  ingredients  that  it  can  digest  and  calories 
that  will  cause  it  to  gain  in  weight — whether  these  be  less 
or  more  than  the  fixed  requirements.  The  best  judge  of 
the  suitability  of  any  formula  is  the  infant  itself.  If  it  ex- 
hibits a  continuous  and  regular  gain  in  weight  and  has  a 
good  digestion  (normal  stools  and  little  or  no  vomiting), 
that  is  the  correct  formula  for  it  regardless  of  its  composi- 
tion as  to  quantity  or  quality.  The  weight  and  the  digestion 
are,  therefore,  the  guides  as  to  the  suitability  of  any  food 
for  the  individual. 

The  first  formula  prescribed  by  the  most  eminent 
dietitian  is  an  experiment.  We  may  start  out  with  the 
idea  that  we  wish  to  give  an  individual  baby,  say,  2 
per  cent,  of  fat,  6  per  cent,  of  sugar,  and  il/2  per  cent,  of 
protein,  and  we  proceed  to<  calculate  this  in  ounces  of  milk, 
cream,  sugar,  and  water.  "Is  there  absolute  accuracy  of 
these  various  percentages  in  the  finished  product?"  We 
do  not  know.  The  chances  are  against  it.  Any  one  of 
the  various  ingredients  may,  and  probably  does,  vary  from 
one-fourth  to  one-half  of  I  per  cent,  too  much  or  too  little. 
The  feeding  of  absolutely  accurate  percentages  is  impossible 
and  unnecessary.  Any  conception  of  percentage  feeding 
that  regards  this  as  one  of  the  possible  advantages  to  be' 
gained  is  fallacious  and  mischievous.  What  percentage 
feeding  should  mean  and  afford  is  an  easy  way  whereby 
any  one  of  the  ingredients  of  the  formula — fat,  protein,  or 


70  ARTIFICIAL  FEEDING. 

sugar — may  be  increased  or  diminished,  and  it  is  the  physi- 
cian's province  to  determine  which  of  these  is  at  fault  by 
studying  the  symptoms  of  the  individual.  What  these 
symptoms  of  the  different  forms  of  indigestion  are  will  be 
stated  under  their  respective  headings.  Recognizing  that 
element  which  is  at  fault,  the  physician  simply  applies 
whatever  method  of  milk  adaptation  he  may  favor  to  the 
case,  and  increases  or  diminishes  the  ingredient,  using  the 
figures  which  represent  percentages  simply  as  a  guide,  not 
caring  whether  those  figures  accurately  represent  the  exact 
amount  or  not.  One  cannot  say  that  the  fat  of  cows'  milk 
is  the  cause  of  all  digestive  disturbances  in  infancy,  any 
more  than  one  can  proclaim  that  infants  will  tolerate  incal- 
culable amounts  of  the  curd  of  cows'  milk ;  nor  can  one  lay 
all  digestive  disturbances  to  protein  or  to  sugar,  or  to  ex- 
cessive caloiry  feeding.  One  cannot  affirm  that  all  infants 
must  be  fed  every  two  hours,  nor  yet  every  four  hours,  nor 
that  quantities  must  be  regulated  by  set  figures  for  the  age. 
Here  again  it  is  necessary  to  individualize  and  to  be  guided 
by  the  digestion  and  the  appetite. 

A  glance  at  the  foregoing  table  will  indicate  certain 
intrinsic  differences  between  cows'  milk  and  human  milk, 
and  it  appears  patent  that  these  must  be  considered  in  any 
scheme  that  would  provide  nourishment  for  the  individual 
baby.  The  most  striking  feature  is  that,  as  it  exists  in  its 
native  state,  the  protein  of  cows'  milk  exceeds  in  amount  by 
about  three  times  that  found  in  human  milk,  and  differs 
intrinsically  in  the  nature  of  the  curd.  Any  system  of 
feeding  that  does  not  recognize  this  as  an  indication  to  feed 
to  an  infant  in  its  early  weeks,  an  amount  of  cows'  curd  less 
than  that  found  in  human  milk,  and  at  the  same  time  to 
change  its  physical  character,  must  necessarily  fail.  Milks 


THEORY  OF  MILK  ADAPTATION.         71 

are  suited  to  the  species,  and  it  is  undoubtedly  true  that  the 
curd  determines  the  future  character  of  the  gastrointestinal 
tract  and  prepares  it  for  the  food  which  it  will  receive  in 
adult  life.  Intestinal  development,  therefore,  depends  upon 
the  nature  of  the  curd  (Chapin).  The  curd  of  cows'  milk 
is  intended  to  develop  the  gastrointestinal  tract  of  a  calf 
into  that  of  a  cow,  and  therefore1  is  suited  to-  the  digestion 
of  a  calf,  while  that  of  human  milk  is  intended  to  develop 
the  guts  of  an  infant  into  those  of  a  man,  and  is  therefore 
suited  to  the  digestive  powers  of  early  life.  Hence)  the 
cows'  curd  must  be  fed  in  small  amounts  at  first  and 
modified  in  nature,  either  mechanically  or  chemically,  until 
tolerance  is  established.  The  extent  of  this  modification 
again  depends  upon  the  digestive  capacity  of  the  individual, 
some  infants  at  an  early  age  being  able  to  tolerate  larger 
amounts  of  protein  than  others  which  are  older. 

The  curd  of  bovine  milk  may  be  dealt  with  in  several 
ways.  The  processes  employed  will  be  described  later,  they 
simply  being  named  here.  In  the  first  place  the  coagulable 
protein  (calcium  paracasein)  may  be  eliminated  entirely  by 
the  feeding  of  whey  in  instances  wherein  protein  intoler- 
ance exists.  The  curd  may  be  attenuated,  i.e.,  be  made  to 
coagulate  in  the  stomach  in  finer  flocculi  by  the  use  of  cereal 
waters  or  gruels, — plain  (Jacobi)  or  dextrinized  (Chapin), 
—flour  ball,  or  by  malt  soup.  It  may  further  be  acted  upon 
so  as  to  pass  through  the  stomach  without  coagulation  by 
the  addition  of  sodium  citrate  (Poynton).  Predigestion,  or 
pancreatization,  and  sterilization  are  other  means  of  render- 
ing the  curd  digestible.  Lastly,  mechanical  division  of  the 
curd  may  be  secured  by  feeding  Finkelstein's  eiweissmilch 
or  buttermilk. 

Unchanged  cow-protein   is  therefore   fed  in   gradually 


72  ARTIFICIAL  FEEDING. 

increasing  amounts  until  a  quantity  is  reached  that  about 
equals  or  slightly  exceeds  that  found  in  human  milk.  One 
must  always,  however,  be  guided  by  the  digestive  powers 
cxf  the  individual.  By  the  time  the  infant  reaches  9  months 
or  a  year  it  may  receive,  if  it  be  healthy,  whole  cows'  milk, 
which  means  about  4^  per  cent,  of  combined  protein.  I 
have  met  a  few  instances  in  which  this  was  safely  tolerated 
at  5^2  months. 

While  occurring  in  about  the  same  amounts,  in  both 
human  and  in  cows'  milk,  it  is  nevertheless  true  that  the 
fat  of  the  latter  is  less  easy  of  digestion.  The  same  rule, 
applicable  to  the  protein,  therefore  applies  here.  The 
amount  of  fat  fed  must  be  gauged  by  the  individual's  ability 
to  appropriate  it.  It  is  best  to  start  with  small  amounts 
and  tq  gradually  increase,  as  a  rule  never  exceeding  4  per 
cent.  In  most  instances  infants  do  better  if  kept  within  this 
amount — from  2,y2  to  3^2  per  cent.  Certain  infants  cannot 
tolerate  fat  at  all.  These  must  be  fed  skimmed  milk,  butter- 
milk, eiweissmilch,  or  the  formula  may  be  pancreatized. 
The  necessity  for  fat,  however,  is  urgent,  as  it  provides 
heat  and  energy  and  conserves  the  proteins  of  the  body.  As 
this  is  also  done  by  the  carbohydrates,  in  instances  wherein 
fat  intolerance  occurs,  the  deficiency  may  be  made  up  by 
the  addition  of  starches  and  sugar. 

The  carbohydrates  of  these  two  milks  are  identical  in 
chemistry,  but  differ  in  amounts.  The  milk-sugar  of  com- 
merce requires  sterilization.  How  are  we  to>  deal  with  the 
carbohydrates?  Personal  experience  would  conclude  that 
infants  bear  sugar  well.  Physiologically  this  is  substan- 
tiated by  the  high  sugar  content  of  human  milk.  Sugar 
provides  heat  and  energy.  The  German  idea  that  milk- 
sugar,  per  se,  is  responsible  for  the  initiation  of  all  cases  of 


THEORY   OF   MILK  ADAPTATION.  73 

summer  diarrhea  appears  to  be  overdrawn,  although  the 
withdrawal  of  sugar  in  the  presence  of  summer  complaint 
undoubtedly  does  good.  So  long  as  micro-organisms  infest 
milk,  so  long  will  their  role,  either  by  causing  toxic  changes 
in  the  milk  itself  or  in  the  intestines  of  the  infant,  be  quite 
potent. 

Milk-sugar  is  not  the  best  carbohydrate  to  add  to  milk, 
for  the  reasons  stated,  that  it  is  unclean,  and  because  it  re- 
quires sterilization  and  readily  ferments.  For  years  Jacobi 
advocated  cane-sugar,  which  is  cheaper,  cleaner,  more  easily 
accessible,  and  ferments  less  readily.  Its  use  is  attended 
by  very  little  digestive  disturbance,  and  has  given  universally 
good  results.  Least  irritating  of  all  sugars,  and  more 
readily  digested  and  quickly  absorbed,  is  maltose.  It  is 
added  in  about  the  same  amounts  as  the  other  sugars 
(Chapter  III,  page  137).  Immediately  after  birth,  most  in- 
fants can  tolerate  from  4  to  5  per  cent,  of  sugar.  This  usu- 
ally may  be  speedily  increased  to  6  or  7  per  cent,  and  at 
about  9  months  is  gradually  reduced  until  at  a  year  4  per 
cent,  is  reached.  This  guide  may  require  variation,  as  the 
individual  digestion  may  indicate.  'Those  infants  which 
bear  sugar  badly  may  be  fed  upon  simple  dilutions  of  whole 
milk,  without  the  further  addition  of  carbohydrate,  or  upon 
buttermilk  or  eiweissmilch.  If  the  absence  of  sugar  makes 
the  food  unacceptable  to  the  infant,  the  sweet  taste  may  be 
supplied  by  the  addition  of  saccharin,  i  grain  to  the  quart. 
Every  ounce  of  sugar  equals  about  120  calories. 

Cows'  milk  is  deficient  in  those  mineral  substances  in 
which  human  milk  is  rich.  To  this  latter  quality  and  to  the 
antibodies,  derived  from  the  mother,  human  milk  probably 
owes  its  antiscorbutic,  antirachitic,  and  immunizing  quali- 
ties. In  the  artificially  fed  it  is  necessary  to  make  up  for 


74  ARTIFICIAL   FEEDING. 

these  deficiencies  by  feeding  to  the  infant,  between  nursings, 
fruit-juices  and  beef-juice.  These  are  rich  in  organic  sub- 
stances and  materially  increase  the  content  of  chlorid  of 
soda.  This  has  a  stimulating  effect  upon  the  gastric  secre- 
tion, thereby  aiding  digestion.  It  is  good  practice  to  add  a 
few  grains  of  common  salt  therefore  to  each  bottle  as  well 
(Jacobi).  This  has  been  my  personal  practice  for  years. 

Human  milk  is  sterile;  cows'  milk  is  not.  This  differ- 
ence must  be  overcome  by  securing  as  clean  a  milk  as  is 
possible.  This  is  accomplished  by  using  certified  milk  or  by 
pasteurization  or  sterilization  (pages  91-94). 

The  reaction  of  cows'  milk  by  the  time  it  reaches  the 
consumer  is  often  acid.  Alkalies  are  to  be  added  with  a 
purpose  in  view,  but  not  routinely.  Sodium  citrate,  sodium 
bicarbonate,  and  lime-water  are  employed.  Their  special 
indications  will  be  detailed  as  we  proceed. 

Summary. — The  various  percentages  of  fat,  protein,  and 
lactose,  as  well  as  the  caloric  requirements,  are  to  be 
adapted  to  the  individual.  In  addition,  animal  and  vegetable 
juices  are  necessary.  Micro-organisms  must  be  eliminated 
or  destroyed.  Alkalies  may  be  required. 

METHODS  OF  MILK  ADAPTATION. 

Percentage  Feeding. — The  various  methods  of  adapting 
cows'  milk  to  the  needs  of  the  infant  have  multiplied  so 
rapidly  that  considerable  confusion  exists  as  to  which  is  the 
best.  Having  stated  the  basic  principle  of  percentage  feed- 
ing, it  follows  that  any  method  will  be  suitable  that  affords 
an  easy  means  of  increasing  or  diminishing  the  ingredients 
of  the  milk.  Two  ways  of  handling  this  problem  are  open 
to  practitioners  of  American  cities — the  Laboratory  Method 
and  the  Home  Method: — 


METHODS    OF   MILK   ADAPTATION.  75 

Laboratory  Method. — This  is  the  easiest  from  the  practi- 
tioner's viewpoint,  and  yet  in  practice  is  the  least  satisfac- 
tory. The  physician  studies  his  patient's  needs,  and  writes 
the  percentages  of  the  different  elements  in  the  milk  as  he 
determines  will  supply  those  needs  and  be  acceptable  to  his 
patient's  digestion.  The  prescription  also  states  the  number 
of  feedings  and  the  amount  of  each  feeding,  together  with 
the  nature  of  the  diluent.  This  is  sent  to  the  laboratory. 
The  completed  formula,  either  in  a  single  container  or  in 
individual  bottles,  containing  sufficient  food  for  one  feeding, 
properly  iced,  is  delivered  to  the  patient's  home  each  day. 
The  physician  may  change  his  prescription  at  any  time. 
Laboratories  have  been  established  in  many  of  the  large 
cities  in  America  by  the  Walker-Gordon  firm,  under  the 
impetus  given  accurate  percentage  feeding  by  Rotch,  of 
Boston.  The  disadvantage  of  this  method  is  that  it  is  not 
available  in  rural  districts.  It  is  costly  and  beyond  the 
reach  of  the  middle  classes  and  the  poor,  who  most  need 
clean  milk.  Further,  as  good  results,  and  perhaps  better, 
can  be  obtained  by  careful  home  modification. 

The  following  represents  a  prescription  form  that  may 
be  used  in  laboratory  feeding: — 


Name Age  

Address  Date  

B  Protein   % 

Fat % 

Sugar % 

Alkali  % 

No.  of  feedings Amount  of  each  feeding 

Character  of  diluent  Maltose,  saccharose,  lactose 

Lime-water Pasteurize  ? 

Sodium  bicarb '. , 

Sodium  citrate 

..M.D. 


76  ARTIFICIAL  FEEDING. 

Home  Method  of  Milk  Adaptation. — That  system  of  milk 
modification  or,  better,  of  milk  adaptation  is  correct  which 
gives  correct  results.  The  simpler  the  means  by  which 
good  results  are  obtained,  the  better  is  the  method;  for  it 
is  more  readily  adopted  by  practitioners,  is  more  easily 
taught  to  the  mother,  and  is  best  for  the  infant.  It  has 
therefore  appeared  to  me,  after  fifteen  years  of  experience 
with  nearly  all  the  methods  proposed,  that  the  simple  dilu- 
tion of  whole  or  of  skimmed  or  of  partly  skimmed  milk  will 
yield  as  good  results  as  the  use  of  top-milks  or  of  those 
formula  derived  from  some  highly  complicated  algebraic 
equation.  By  means  of  the  simple  dilution  of  whole  or  o>f 
skimmed  milk  we  need  not,  nor  indeed  we  should  not,  dis- 
card the  percentage  nor  even  the  caloric  idea.  Both  are 
•founded  upon  sound  scientific  reasoning,  and  both  are  o-f 
use  provided  they  do  not  cause  one  to  become  narrow  and 
dogmatic.  Percentages  should  simply  be  regarded  as  rep- 
resenting certain  degrees  of  strength,  and  the  numbers 
employed  to  represent  the  percentages  should  never  be  con- 
sidered to  mean  absolutely  the  exact  amount  of  fat,  sugar, 
or  protein,  as  the  case  may  be,  as  is  stated.  This  is  impos- 
sible ;  likewise  it  is  unnecessary.  The  numbers  employed  to 
represent  percentages  might  just  as  well  be  indicated  by  a 
letter.  Thus  P.  i  per  cent,  and  P.  2  per  cent,  could  be 
written  Pa,  Pb,  each  advancing  letter  standing  for  a  degree 
of  strength  of  protein  stronger  than  the  preceding  letter. 
The  same  applies  to  the  varying  strengths  of  fat  and  of 
sugar  which  may  be  desired.  The  idea  is  not  to  feed  accu- 
rate percentages  of  each  ingredient,  but  to  have  a  means  of 
increasing  or  of  diminishing  any  particular  substance  which 
the  clinical  condition  may  indicate.  The  same  is  true  with 
reference  to  the  caloric  requirements  of  the  individual.  Any 


METHODS    OF   MILK   ADAPTATION.  77 

formula  may  be  checked,  and  thus  one  will  be  able  in 
the  individual  case  to  note  whether  the  particular  baby  is 
receiving  a  sufficient  number  of  heat  units. 

From  the  foregoing  it  must  be  realized  that  without 
the  use  of  common  sense  one  need  not  expect  to  become 
a  successful  feeder  of  infants.  The  keynote  of  the  whole 
situation  is  that  the  individual  must  be  studied  from  the 
standpoints  of  his  appetite,  his  strength,  his  caloric  require- 
ments,— above  all,  from  the  standpoint  of  his  digestive 
capabilities.  He  who  would  be  successful  must  therefore 
be  a  good  reader  of  stools,  and  must  be  able  to  interpret  the 
macroscopic  appearance  of  the  excreta  properly,  and  to  de- 
termine the  individual's  ability  to  take  care  of  the  fat,  sugar, 
and  protein.  These  points  have  just  been  detailed  on  pages 
32-34.  It  may,  however,  again  be  emphasized  that  the  main 
indices  as  to  the  value  of  any  particular  food  are  a  con- 
tinuous and  substantial  weekly  gain  in  weight  and  normal 
stools.  If  the  latter  are  present  and  the  infant  is  receiving 
a  sufficient  quantity  of  food,  the  former  must  follow  as  a 
natural  consequence.  It  is  inevitable.  Therefore  the  first 
formula  would  be  written  about  as  follows : — 

Skimmed  milk 2.5  oz. 

Diluent  17.5  oz. 

Sugar I  .o  oz. 

Salt    I      pinch. 

As  stated  previously,  this  is  an  experiment,  as  all  first 
formulae  are,  even  in  the  best  of  hands.  Upon  this  the  in- 
fant may  not  immediately  gain.  Skimmed  milk  is  employed 
in  the  beginning  simply  to  "play  safe."  Fat  is  a  common 
disturber  of  digestion,  and  therefore,  at  the  outset,  fat  is 
temporarily  omitted  or  reduced  to  a  minimum.  Our  guides 
— the  stools  and  the  weight — are  now  consulted.  As  just 


78  ARTIFICIAL   FEEDING. 

stated,  one  would  not  as  yet  expect  a  gain.  However,  it  is 
assumed  that  the  stools  appear  normal  and  that  the  infant 
does  not  vomit.  We  now  proceed  cautiously.  We  employ 
half-skimmed  milk  in  the  same  proportions  as  we  employed 
the  wholly  skimmed  milk.  The  mother  is  instructed  to 
remove  all  the  cream,  and  then  to  pour  back  into  the  bottle 
half  of  that  which  was  removed.  The  whole  is  well  shaken 
up  and  the  second  formula  is  made  up  as  follows : — 

Half-skimmed  milk  2.5  oz. 

Diluent 17.5  oz. 

Sugar i.o  oz. 

Salt   I     pinch. 

It  is  again  assumed  that  this  slight  addition  of  fat  causes 
no  disturbance.  In  a  day  or  two  the  mother  is  instructed  to 
shake  up  well  the  whole  quart  of  milk  and  to  employ  a 
formula  as  follows: — 

Whole  milk 2.5  oz. 

Diluent  17.5  oz. 

Sugar i.o  oz. 

Salt i  pinch. 

No  disturbance  occurring,  in  daily  succession  we  speedily 
change  the  formula  as  indicated :  — 

Whole  milk 4  oz. 

Diluent    16  oz. 

Sugar i  oz. 

Salt i  pinch. 

And  then  too: — 

Whole  milk  5  oz. 

Diluent 15  oz. 

Sugar i  oz. 

Salt i  pinch. 

From  this  point  onward  if  the  digestion  be  good  the  baby 
should  commence  to  gain  from  %  to  i  ounce  a  day  or  from 
5  to  7  ounces  per  week.  The  questions  to  be  answered  now 


METHODS   OF   MILK   ADAPTATION.  79 

are:  "When  shall  the  strength  of  the  formula  be  changed 
again?"  and  "When  shall  the  amount  of  each  feeding  be  in- 
creased?" The  safest  rule  to  follow  in  my  own  experience 
is  to  make  no  change  until  the  infant  ceases  to  gain  on  its 
food.  Let  a  stationary  weight  or  a  slight  loss  therefore  be 
our  index  for  action  in  a  case  that  has  been  continuously 
gaining  and  digesting  well. 

We  may  now  do  one  of  three!  things,  viz.,  (a)  Increase 
the  strength  of  the  milk  in  the  formula,  (b)  Increase  the 
amount  of  each  feeding,  (c)  Do  both. 

The  last  is  bad  practice.  It  is  unwise  to-  increase 
the  amount  of  the  feed  when  the  strength  of  the  formula  is 
increased,  i.e.,  it  is  bad  to  do  both  simultaneously.  The 
latter  should  be  done  a  day  or  two  after  the  former,  when 
it  is  seen  that  the  increase  in  the  strength  of  the  formula 
has  caused  no  disturbance.  "What  should  be  the  size  of  the 
increment  in  the  milk  content  of  the  formula  ?"  and  "What 
should  be  the  size  of  the  increment  of  the  bulk  of  the  meal  ?" 
The  latter  will  be  answered  first.  The  quantity  added  to 
each  meal  should  never  exceed  i  ounce,  and  it  had  better  be 
not  more  than  l/2  ounce.  Thus,  if  10  meals  were  given 
daily,  this  would  mean  the  increase  of  from  10  to  5  ounces 
in  the  total  bulk  of  the  food  per  diem.  The  strength  of 
the  formula  may  be  increased  as  follows,  meanwhile  making 
daily  inspections  of  the  stools : — 

Whole  milk  6  oz. 

Diluent 14  oz. 

Sugar i  oz. 

Salt i  pinch. 

Whole  milk   7  oz. 

Diluent  13  oz. 

Sugar  i  oz. 

Salt  i  pinch. 


80  ARTIFICIAL   FEEDING. 

Whole  milk 8  oz. 

Diluent  12  oz. 

Sugar  '. .     i  oz. 

Salt I  pinch. 

And  so  on,  the  guide  to  change  from  one  strength  to  a 
higher  concentration  meanwhile  being  a  cessation  in  the 
continuous  weekly  gain,  as  previously  stated. 

Weighing  should  never  be  practised  oftener  than  twice 
weekly,  and  preferably  but  once  weekly,  fo<r  the  reason 
that  too  frequent  weighing  causes  discontent,  disturbs  the 
mother,  and  is  likely  to  warp  the  physician's  good  judgment, 
thereby  causing  him  to  make  changes  in  the  food  too 
frequently. 

Thus  this  method  of  increasing  the  strength  and  then 
the  size  of  the  meal  is  persistently  pursued  toward  the  end, 
until  the  infant  receives  whole  undiluted  cows'  milk.  This 
is  the  goal.  "When  is  this  reached?"  is  a  pertinent  ques- 
tion. Not  meaning  to  give  an  asinine  answer,  the  best 
reply  in  my  experience  is  that  it  is  reached  "when  it  is." 
The  idea  intended  to  be  implied'  is  that  there  can  be  no 
definite  age  limit.  The  digestive  capabilities  of  the  in- 
dividual can  alone  determine  this  point.  It  may  be  at  6 
months,  slightly  before,  or  not  until  9  months  or  I  year. 
The  individual's  digestive  capacity  can  only  be  determined 
by  cautiously  proceeding  according  to  the  method  indicated, 
of  replacing  an  ounce  of  diluent  by  an  ounce  of  milk  and 
then  slightly  increasing  the  size  of  the  meal  and  watching 
the  effect.  If  this  be  for  good,  advance  is  made  by  employ- 
ing the  next  stronger  formula.  If  it  disturbs  the  digestion 
we  return  again  to  the  formula  immediately  preceding,  or  to 
a  still  weaker  one,  or  we  may  adopt  one  or  another  of  the 
maneuvers  described  in  fat,  sugar,  or  protein  intolerance,  as 
the  case  may  be. 


PLATE  VII 


Hard,  constipated,  calcium-soap  stool.  Commonly  seen  where  too 
much  fat  is  administered  in  the  formula.  The  fatty  acids  combine  with 
the  mineral  substances  contained  in  the  intestinal  mucus,  which  is  in- 
creased as  a  result  of  the  irritating  effect  of  these  acids.  For  this 
reason  the  passage  of  this  constipated  movement  may  be  accompanied 
or  followed  by  loose  material.  These  babies  either  remain  stationary 
or  lose  in  weight,  and  often  have  an  ammoniacal  urine.  For  treatment, 
see  text  on  fat  intolerance.  This  stool  is  also  of  good  prognostic  sig- 
nificance in  cases  of  diarrhea  which  have  been  placed  upon  buttermilk 
or  eiweissmilch,  the  calcium  casein  of  these  preparations  combining 
with  the  fatty  acids,  producing  the  caseate  of  lime  or  calcium-soap 
stool.  \Yheii  this  is  secured  a  return  may  be  made  to  diluted-milk 
formulas. 


METHODS    OF   MILK   ADAPTATION.  81 

If  at  any  time  during  the  course  of  a  feeding  case  it  is 
deemed  necessary  to  determine  the  percentage  strength  of 
the  formula  which  the  infant  is  receiving,  or  to  note  its 
caloric  value,  this  can  readily  be  accomplished  roughly 
with  reference  to  the  percentage  of  fat,  sugar,  and  protein 
by  regarding  cows'  milk  as  a  "four,  four,  four  mixture," 
that  is,  F.  4  per  cent.,  L.  4  per  cent.,  P.  4  per  cent. 

Example: — 

Milk   5  oz. 

Diluent 15  oz. 

Sugar   i  oz. 

Fat  =  %o  =  &    V*  of  4%  =  i  %• 

Therefore,  since  each  ingredient  equaled  4%,  we  would 
have  F.  i  % ,  L.  i  % ,  P.  1%.  To  this  however  i  ounce  of 
sugar  has  been  added;  therefore,  as  i  ounce  in  20  equals 
1/2o  or  5%  extra  carbohydrate,  this  is  added  to  the  i% 
obtained  originally  from  the  milk.  Consequently,  the  total 
carbohydrate  equals  1%  plus  5%,  or  6%.  The  final  for- 
mula consequently  would  read:— 

F.  1%,  L.  6%,  P.  1%. 

Rule  to  Determine  the  Percentage  Strength  of  any 
Formula  of  Diluted  Whole  Milk. — Divide  the  number  of 
ounces  of  whole  milk  used  by  the  number  representing  in 
ounces  the  total  bulk  of  the  mixture.  Multiply  the  result- 
ing fraction  by  4.  To  the  result  obtained  with  reference  to 
the  sugar  add  the  result  secured  by  dividing  the  number 
of  ounces  of  additional  sugar  by  the  number  representing 
in  ounces  the  total  bulk  of  the  formula,  and  multiply  this 
by  100.  Add  this  number  to  the  number  obtained  with  ref- 
erence to  the  sugar  percentage. 

The  caloric  value  of  the  mixture  is  readily  determined 
by  multiplying  each  ounce  of  milk  by  21  and  each  ounce  of 


82  ARTIFICIAL  FEEDING. 

sugar  by  120  and  by  adding  these  together.  Of  course  if 
the  mixture  totals  40  oz.  and  if  in  twenty-four  hours  the 
child  receives,  say,  but  30  oz.  of  this,  then  the  total  num- 
ber of  calories  actually  received  by  the  child  in  twenty-four 
hours  represents  80/40  or  24  of  the  total  number  of  calories 
represented  by  the  entire  f ormula.  (  See  next  page. ) 

It  will  be  noticed  that  all  of  the  formulae  preceding  are 
calculated  in  total  amounts  of  20  ounces.  This  has  been 
adopted  merely  as  a  matter  of  convenience  and  of  habit. 
If  the  total  daily  quantity  of  formula  equals  25,  30,  35,  or 
40  ounces,  then  each  ingredient  in  the  2O-ounce  formula 
must  be  multiplied  by  1.25,  1.50,  1.75,  or  2  as  the  case 
may  be. 

The  sugar  which  is  added  is,  for  practical  purposes,  dis- 
regarded as  far  as  its  influence  upon  increasing  the  total 
volume  of  the  formula  is  concerned.  It  must  be  further 
stated  that,  as  the  concentration  of  the  formula  increases  and 
approaches  the  strength  of  24  milk  and  ^4  diluent,  the  sugar 
is  gradually  decreased  by  %  ounce  amounts  in  the  20- 
ounce  mixture  until  it  is  finally  omitted. 

Calory  Feeding. — This  is  a  method  of  feeding  based  on 
the  caloric  requirements  of  the  infant  as  determined  by  its 
weight.  An  infant  up  to  6  months  needs  approximately 
about  loo  calories  per  kilogram  of  body  weight,  or  about 
45  calories  per  pound.  As  the  child  approaches  a  year  the 
caloric  requirement  is  somewhat  less — between  85  and  80 
calories  per  kilo,  or  32  to  35  per  pound.1  These  figures 

1  The  exact  figures  given  by  Heubner  and  Rubner  are  as  fol- 
lows:— 

First  3  months 100  calories. 

Second  3  months  90  calories. 

Third  3  months  80  calories. 

Fourth  3  months  70  calories. 


METHODS   OF   MILK   ADAPTATION.  83 

have  reference  to  healthy  infants.  Some  undernourished 
or  premature  babies  require  as  high  as  125  to  175  calories. 
One  quart  of  cows'  milk  equals  680  calories.  One  quart  of 
human  milk  equals  615  calories.  Allen  has  concluded  that, 
in  order  to  maintain  nitrogen  equilibrium,  it  is  necessary 
for  the  infant  to  receive  the  protein  contained  in  i  ounce 
of  cows'  milk  for  every  pound  of  body  weight.  There- 
fore if  it  be  desired  to  provide  for  body  growth  and 
development  in  addition,  it  is  necessary  to  give  from  1^2 
to  2  ounces  of  -cows'  milk  for  every  pound  of  weight. 
Hence,  to  determine  how  much  milk  is  to  be  employed  in 
the  formula,  the  weight  is  multiplied  by  1^2  or  2.  This 
result  is  deducted  from  the  total  quantity  of  food  required 
in  twenty-four  hours  in  order  to  learn  the  amount  of 
diluent  necessary.  Any  deficiency  of  caloric  value  is  made 
up  by  adding  carbohydrate  in  the  form  of  lactose,  saccharose, 
or  maltose,  preferably  the  last  two.  One  ounce  of  all 
sugars  by  weight  about  equals  120  calories.  One  ounce  of 
4  per  cent,  milk  approximates  21  calories. 

Example. — A  healthy  infant  6  months  old  weighs  15 
pounds  and  is  receiving  7  ounces  of  food  six  times  a  day. 
Total  quantity  in  twenty-four  hours  equals  6  multiplied  by 
7,  or  42  ounces. 

IS  X  45  =  675  calories  required  in  twenty-four  hours. 
IS  x  1-5  =  22.5  oz.  milk. 
42 —  22.5  =  19.5  oz.  of  diluent. 
22.5  X  21  =  4/2.5  calories  provided  by  the  milk. 
675  —  472.5  =  202.5  calories,  which  can  be  supplied  approximately 
by  1.75  oz.  of  sugar  =  210  calories. 

The  infant  therefore  receives  472.5  +  210  =  682.5 
calories. 

Advantages  of  This  Method. — Its  simplicity  at  once 
appeals.  All  that  is  necessary  is  to  multiply  the  infant's 


84  ARTIFICIAL  FEEDING. 

weight  by  1.5.  Add  sufficient  diluent  to  bring  up  the  bulk 
of  the  food  to  the  twenty-four-hour  requirement  and  suffi- 
cient carbohydrate  to  raise  the  caloric  value  to  the  weight 
requirement.  As  a  check  upon  percentage  feeding  it  is 
valuable  in  that  it  permits  the  physician  to1  know  whether 
he  is  feeding  under  or  above  the  food  tolerance  for  the 
individual. 

Disadvantages  of  This  Method. — It  does  not  take  into 
consideration  the  strength  of  the  food.  Thus  an  infant  o>f 
3  months  weighing  7  pounds  would  receive  a  much  weaker 
mixture — as  the  total  amount  of  food  would  be  greater — 
than  an  infant  of  I  week  weighing  7  pounds.  In  the  latter 
instance  the  strength  of  the  food  would  probably  be  too 
great,  as  the  total  daily  bulk  would  be  less,  and  therefore 
the  milk  would  not  be  sufficiently  diluted. 

Caloric  feeding  completely  ignores  the  digestive  capacity 
of  the  individual  baby,  taking  cognizance  alone  of  the  heat 
units  required.  Further,  in  order  to  receive  the  number  of 
calories  necessary,  the  entire  amount  of  the  milk  mixture 
provided  for  twenty-four  hours  must  theoretically  be  con- 
sumed within  that  space  of  time.  As  a  practical  proposition 
this  is  often  impossible,  due  to  the  vagaries  of  the  infant's 
appetite  as  well  as  to  other  unpreventable  causes. 

Experience  seems  to  show  that  in  order  to  make  the 
baby  gain  in  weight  it  is  necessary  to  provide  more  calories 
than  45  per  pound  of  body  weight.  Often  one  and  one- 
half  and  even  twice  this  number  must  be  given.  If  one 
adopts  calory  feeding  as  his  method  of  nourishing  infants, 
he  may  become  as  dogmatic  in  his  statements  as  one  who 
adheres  entirely  to-  percentage  feeding.  In  order  to-  be  suc- 
cessful it  is  necessary  to  individualize  as  in  any  other 
method. 


METHODS    OF   MILK   ADAPTATION.  85 

In  ordering  a  milk  mixture,  whether  percentage  or 
calory,  the  following  form  has  proved  to  be  useful  when 
handed  to  the  child's  caretaker. 

Name Date 

Weight Age  

Fat  per  cent.        Sugar per  cent. 

Protein    per  cent.         Daily  Amount  

(Make  fresh  daily.) 
Calories  required   

Milk    oz. 

Skimmed  milk   oz. 

Cream  oz. 

Whey    oz. 

Barley-water    oz. 

Oatmeal-water   oz. 

Boiled  water oz. 

Rice-water   oz. 

Lime-water   oz. 

Sugar  oz. 

Salt. 

(  Soda  cit 

Medicine     J.  Saccharin 

(  Other 

Pancreatized  minutes. 

Feed  oz.  every  hours,  giving  oz. 

in  twenty-four  hours. 

Diluents. —  Of  the  diluents  employed  with  cows'  milk, 
water  probably  enjoys  the  largest  field  of  usefulness. 
Aside  from  its  diluting  properties,  it  is  a  valuable  thera- 
peutic agent  when  used  intelligently.  It  is  essentially  a  food 
and  is  necessary  for  the  digestion  and  assimilation  of  all 
other  foods.  Without  it  the  physiologic  activity  of  the 
economy  would  cease.  It  not  only  allays  thirst,  but  in 
physiologic  quantities,  administered  regularly,  it  increases 
the  flow  of  gastric  juice.  It  renders  soluble  the  salts  of  the 
gastric  contents  and  prepares  them  for  absorption.  By  in- 
creasing the  fluidity  of  the  intestinal  contents  it  acts  as  a 
laxative  and  prevents  constipation.  It  dissolves  and  dilutes 


86  ARTIFICIAL   FEEDING. 

toxins,  favoring  their  elimination  through  the  skin  and  kid- 
neys. It  maintains  blood-pressure.  It  forms  the  main 
component  part  of  every  secretion  and  excretion  of  the 
body.  It  favors  the  deposition  of  fat. 

As  a.  diluent  therefore  in  milk  mixtures  it  forms  an 
invaluable  addition  as  a  nutritive  agent.  While  its  action 
is  to  dilute  all  the  ingredients  of  the  milk,  it  does  not,  to  any 
considerable  extent,  change  their  physical  characters.  The 
curd  formed  by  rennin  with  milk,  diluted  with  water,  is 
almost  as  tough  and  dense  as  that  obtained  with  undiluted 
cows'  milk. 

To  overcome  this  Jacobi,  many  years  ago',  first 
devised  the  use  of  cereal  decoctions,  for  which  he  claimed 
the  power  of  mechanically  dividing  the  tough  curd  of  cows' 
milk  into  a  fine,  flocculent,  porous  curd.  For  this  purpose 
he  recommended  the  use  of  barley-,  wheat-,  oatmeal-,  and 
rice-  water.  Barley-,  wheat-,  and  rice-  water  are  to  be 
employed  when  diarrhea  exists,  and  oatmeal-water  is  added 
as  a  diluent  with  constipated  children. 

Dextrinized  gruels  are  advocated  as  a  diluent,  especially 
by  H.  D.  Chapin  and  Keller.  They  go  a  step  farther  in 
the  use  of  plain  cereal  decoctions.  Instead  of  using  the 
plain  cereal-water  or  thin  gruel,  they  submit  the  latter  to 
the  action  of  some  diastatic  agent,  thereby  changing  the 
starch  to  dextrin. 

The  efficacy  of  dextrinized  gruel,  made  from  wheat- 
flour,  has  been  tested  in  a  number  of  feeding  cases  in  the 
Medico-Chirurgical  and  in  the  Philadelphia  General  Hos- 
pitals. It  was  added  to  the  milk  mixture,  as  a  diluent, 
in  the  same  amount  as  the  formula  called  for  water,  the 
gruel  taking  the  place  of  water.  The  first  case  did  remark- 
ably well,  the  child  gaining  in  weight  on  an  average  of  il/2 


METHODS    OF   MILK   ADAPTATION.  87 

ounces  a  day,  curds  disappearing  from  the  stools,  which 
became  normal  in  appearance.  Other  children,  all  infants 
under  I  year  of  age,  showed  varying  results.  Some  grew 
fat  and  strong,  others  showing  no  change  either  in  weight 
or  in  the  character  of  their  stools.  In  the  test-tube  the 
addition  of  dextrinized  gruel  certainly  causes  the  milk  to 
coagulate  in  fine,  feathery,  flocculent  curds,  when  acted  upon 
by  rennin.  In  the  stomach  of  some  infants  the  effect  is 
decidedly  different.  One  case  of  miliary  tuberculosis,  which 
came  to  autopsy,  showed  a  large,  dense,  tough  curd  in  the 
stomach  after  having  been  fed  four  hours  before  death  with 
a  mixture  which  contained  only  0.25  per  cent,  of  protein. 
This  may  have  been  due  to  insufficient  gastric  motor  power 
or  to  large  doses  of  subgallate  of  bismuth  which  was  ad- 
ministered to  control  intestinal  hemorrhage.  Koplik  has 
made  use  of  dextrinized  gruels  in  about  50  cases  of  subacute 
and  chronic  enteric  catarrh  associated  with  marasmus.  He 
believes  this  method  of  feeding  to  be  of  service  in  older 
children  who  refuse  milk.  He  quotes  Keller's  experience 
as  finding  the  amount  of  ammonia  in  the  urine  diminishing 
in  marantic  infants  who  suffer  from  an  acid  intoxication 
of  the  gut. 

Barley-water. — Scald  one  tablespoonful  of  white  pearl 
barley  and  throw  away  the  water.  One  quart  of  water  is 
then  poured  over  the  barley.  It  is  allowed  to  boil  down  to 
one  pint  and  is  strained.  Barley-water  is  useful  for  a  short 
time  in  the  treatment  of  the  summer  diarrheas  as  a  substi- 
tute for  milk.  It  contains  a  small  amount  of  nourishment 
and  is  constipating.  It  is  a  useful  vehicle  for  the  adminis- 
tration of  stimulants.  It  is  also  added  to  milk  as  a  sub- 
stitute for  water  to  attenuate  the  curds  in  the  presence  of 
protein  indigestion. 


88  ARTIFICIAL  FEEDING. 

Barley-gruel  or  Barley-jelly. — Two  to  three  ounces  o,f 
barley-flour,  either  Robinson's  or  that  prepared  by  the  Cereo 
Company  of  Tappan,  N.  Y.,  are  rubbed  into  a  smooth  paste 
with  water  and  then  sufficient  water  added  to  make  one  pint. 
Boil  with  constant  stirring1  for  twenty  minutes,  add  suffi- 
cient hot  water  to  make  up  for  the  amount  evaporated,  salt 
to  taste.  When  cool  the  substance  sets  into  a  thick  jelly. 
In  making  the  gruel  a  little  less  barley-flour  is  used. 

Oatmeal-water. — This  is  of  service  in  the  attenuation  of 
the  curd  of  cows'  milk  when  used  as  a  diluent  in  place  of 
plain  water,  especially  in  the  presence  of  constipation.  Add 
one  tablespoonful  of  oatmeal  to  one  pint  of  boiling  water. 
Simmer  for  thirty  to  sixty  minutes.  The  bulk  is  again 
brought  up  to  a  pint  by  the  addition  of  boiling  water. 
Strain.  Salt  to  taste. 

Oatmeal-gruel  or  Jelly. — This  may  be  made  either  from 
the  plain  oatmeal  or  from  Cereo  oat-flour.  In  the  latter 
instance  the  preparation  is  similar  to  barley-gruel  or  barley- 
jelly.  In  the  former  three  to  four  ounces  of  oatmeal  are 
added  to  one  pint  of  water.  Boil  for  three  hours,  prefer- 
ably in  a  double  boiler.  Water  is  added  in  the  mean  time  to 
make  up  for  evaporation.  Strain.  Salt  to  taste.  When 
cool  it  jellies.  It  may  be  fed  in  this  way  or  added  to'  milk 
in  varying  amounts  to  attenuate  the  curd. 

Wheat-flour  Water. — This  may  be  used  as  a  diluent  of 
milk  in  the  presence  of  diarrhea.  One  to  two  teaspoonfuls 
of  wheat-flour  are  added  without  lumping  to  one  pint  of 
water.  Boil  thirty  minutes.  Stir  constantly.  Add  suffi- 
cient water  to  a  pint.  Strain.  Salt  to  taste. 

Arrowroot- water.— Rub  one  teaspoonful  of  arrowroot 
into  a  smooth  paste  with  a  little  cold  water.  Add  to  one 
pint  of  hot  water.  Boil  five  minutes  with,  constant  stirring. 


METHODS    OF   MILK   ADAPTATION.  89 

Rice-water. — This  is  used  as  a  milk  diluent  in  cases  of 
diarrhea,  or  may  be  given  plain  to  the  infant.  One  table- 
spoonful  of  clean  rice  is  covered  with  a  quart  of  warm  water 
and  permitted  to  stand  for  one  hour.  Boil  until  the  volume 
is  reduced  to  one  pint.  Strain.  Salt  to  taste. 

Dextrinized  Gruels. — Dextrinized  gruels  are  made  either 
from  wheat-,  barley-,  oatmeal-,  or  rice-  flour  in  the  follow- 
ing manner:  One  to  two  tablespoonfuls  of  any  of  these 
flours  is  stirred  into  a  thin,  smooth  paste  with  a  little  water. 
This  is  added  to  one  pint  and  a  half  of  water  and  boiled  for 
fifteen  or  twenty  minutes  with  constant  stirring,  using  a 
long-handled  spoon.  The  gruel  is  then  removed  from  the 
fire  and  allowed  to  cool.  When  cool  enough  to  taste,  one 
teaspoonful  of  a  preparation  of  diastase  is  added  and  mixed 
well  with  it.  Upon  the  addition  of  diastase  the  gruel  at 
once  becomes  thin-  and  watery;  5;  to  10  grains  of  taka- 
diastase  may  be  dissolved  in  a  teaspoonful  of  water.  Use 
may  be  made  of  any  preparation  of  malt,  as  Liebig's  malt 
extract  or  of  Cereo,  which  is  a  glycerite  of  diastase. 

Malt  Soup. —  In  1898  Keller  published  reports  of  his 
experiments  at  the  University  Childrens'  Clinic  in  Breslau. 
The  preparation  of  choice  is  Loeflund's  malt  soup.  It  is 
a  thick,  syrupy  substance  of  brownish  color  and  pleasant 
odor.  It  contains  potassium  carbonate,  the  purpose  of 
which  is  to  overcome  the  acidity  of  the  malt.  It  is  employed 
as  follows :  From  i  to  2  ounces  of  malt  soup  are  added  to 
i  pint  of  warm  water  (solution  No.  i).  From  I  to  3 
ounces  by  measure  of  wheat-flour  are  smoothly  mixed  with 
i  pint  of  milk  and  strained  (solution  No.  2).  The  two 
solutions  are  mixed  and  slowly  brought  to  a  boil  with  con- 
stant stirring.  Cool  and  bottle.  The  amount  of  malt  soup 
and  flour  may  be  varied  as  indicated.  If  diarrhea  or  vomit- 


90  ARTIFICIAL   FEEDING. 

ing  occur,  less  malt  is  employed;  if  abdominal  distention, 
less  flour.  On  the  other  hand,  the  proportions  of  milk  and 
water  may  be  adjusted  to  suit  any  desired  percentages. 
The  effect  of  mixing  these  solutions  is  to  provide  a  dex- 
trinized  cereal — dextrin  and  maltose. 

Milk  prepared  in  this  way  has  undoubtedly  a  large  field 
of  usefulness  in  marantic  infants  whose  digestive  organiza- 
tion is  so  delicate  that  it  is  next  to  impossible  to  secure  a 
food  that  will  agree  or  produce  a  gain  in  weight.  Cases  of 
essential  marasmus  often  gain  with  tremendous  strides  when 
placed  upon  this  food.  Cases  which  have  difficulty  in 
digesting  the1  curd,  but  show'  a  tolerance  for  starch,  are 
benefited,  while  those  that  vomit  and  have  diarrhea  do  not 
thrive  upon  this  food.  The  addition  of  malt  soup  should 
not  be  permanent,  but  is  only  to  be  employed  for  the  pur- 
poses indicated — especially  protein  indigestion — and  grad- 
ually discontinued  when  the  bowels1  are  normal  or  the 
weight  ceases  to  increase.  It  is  especially  useful  in  cases 
which  show  acidosis  as  the  ammonium  output  is  decidedly 
lessened. 

Alkalies. — Although,  as  stated,  by  the  time  that  cows' 
milk  reaches  the  consumer  it  is  slightly  acid,  alkalies  are 
not  to  be  employed  routinely,  but  for  a;  distinct  indication. 
This  indication  is  to  overcome  hyperacidity,  to  assist  in  pro- 
tein indigestion,  and  to  overcome  the  effects  of  acidosis 
attendant  upon  too  much  fat  in  the  food,  as  indicated  by  an 
ammoniacal  urine.  Of  alkalies  lime-water  is  the  most  com- 
monly employed  in  the  amount  of  from  5  per  cent,  (com- 
mon) to  as  much  as  20  to  30  per  cent,  of  the  milk  mixture. 
Besides  overcoming  acidity,  it  causes  the  curd  to  become 
attenuated  and  improves  the  flavor  of  the  milk. 


METHODS  OF   MILK   ADAPTATION.  91 

Sodium  citrate  finds  its  greatest  advocates  in  Wright 
and  Poynton,  of  England,  and  Vaderslice  and  Cotton,  of 
Chicago.  It  is  added  to  milk  in  the  strength  of  from  I  to  3 
grains  for  every  ounce  of  milk  and  cream  in  the  mixture. 
It  prevents,  if  in  sufficient  strength,  coagulation  of  the  milk 
in  the  stomach,  thereby  entirely  eliminating  gastric  diges- 
tion. As  can  readily  be  appreciated,  this  is  not  desirable 
as  a  routine  measure,  weak  digestion  would  be  an 
indication,  especially  where  the  motor  function  is  impaired 
or  in  cases  of  pyloric  obstruction.  The  addition  of  sodium 
citrate,  gr.  10  to  gr.  30,  before  each  feeding,  either  in 
the  breast-  or  bottle-  fed,  is  a  valuable  means  of  seeking  to 
allay  vomiting  by  permitting  the  milk  to  pass  more  readily 
into  the  duodenum  on  account  of  its  unclotted  condition. 
The  exact  manner  of  the  action  of  sodium  citrate  is  un- 
known. It  is  assumed  that  the  citric  acid  liberated  combines 
with  the  lime-salts  of  the  milk,  forming  citrate  of  calcium. 
The  calcium  being  thus  bound,  the  free  sodium  unites  with 
the  free  casein  to  form  sodium  paracasein,  which,  in  con- 
tradistinction to  the  curd,  calcium  paracasein,  is  in  solution. 

Sodium  bicarbonate  is  not  commonly  employed,  but  is 
indicated  in  hyperacidity,  and  is  used  in  the  strength  of 
from  i  to  5  grains/  for  every  ounce  of  milk  and  cream  in 
the  mixture. 

Pasteurized  Milk. — This  means  the  process  by  which  the 
milk  is  subjected  to  a  temperature  of  155°  F.  for  a  period 
of  about  thirty  minutes  to  an  hour,  after  which  it  is  rapidly 
cooled  to  68°  F.  The  best  means  of  pasteurizing  is  by  the 
Freeman  instrument  (Fig.  17).  This  consists  of  a  metal 
bucket  or  pail  which  has  a  removable  lid  (A}  and  a  groove 
encircling  it  about  one-third  from  the  bottom.  In  this 
bucket  fits  a  metal  rack  (B),  which  is  made  to  hold  bottles 


92 


ARTIFICIAL   FEEDING. 


(C).  Two  sizes  are  made:  one  holding  10  bottles,  the 
capacity  of  which  is  6  oz.,  and  one  holding  7  bottles,  the 
capacity  of  which  is  8  oz.  The  rack  has  a  wire  crosspiece 
(/})  by  means  of  which  it  can  be  raised  when  the  cross- 
piece  is  made  to  rest  on  a  metal  support  (E)  which  projects 
into  the  bucket. 


Fig.  17. — Freeman's  pasteurizer.  A,  cover;  B,  metal  rack;  C,  bot- 
tles; D,  crosspiece;  E,  support;  F,  separate  compartments.  (Physi- 
cian's Supply  Co.,  Phila.,  Pa.) 

The  pasteurizer  is  filled  to  the  groove  with  water  and 
placed  over  a  hot  fire.  When  the  water  boils,  each  bottle, 
after  being  sterilized  and  having  been  filled  with  the  desired 
quantity  of  milk  mixture,  is  stoppered  with  sterile  cotton 
and  placed  in  its  own  compartment  (F)  in  the  metal  bracket, 
and  cold  water  is  allowed  to  run  into  each  compartment. 
Any  compartments  that  do  not  contain  milk  formulas  are 
occupied  by  bottles  filled  with  water.  The  rack  is  then 
placed  in  the  pail  containing  the  boiling  water.  The  lid  of 
the  pasteurizer  is  now  adjusted  and  the  apparatus  is  taken 


METHODS    OF    MILK   ADAPTATION.  93 

from  the  fire.  It  is  left  undisturbed  for  from  thirty  minutes 
to  one  hour,  when  it  is  carried  under  a  faucet  of  cold  water, 
the  lid  removed,  and  the  rack  raised  so  the  crosspiece  (D) 
rests  on  the  metal  support  (E)  which  projects  into  the 
bucket,  and  cold  water  is  permitted  to  run  into'  the  pail, 
thus  rapidly  displacing  the  hot  water.  The  bottles  are  now 
removed  from  the  rack,  stoppered  with  sterile  cork  stop- 
pers, and  placed  on  ice.  Before  feeding  they  are  slightly 
warmed  by  being  placed  in  warm  water. 

While  it  is  true  pasteurization  does  not  make  a  dirty 
milk  clean  nor  a  fit  food  for  infants,  it  is  the  best  and  safest 
procedure  we  at  present  possess.  It  is,  perhaps,  a  good 
rule  to  pasteurize  all  milk,  even  when  the  method'  of  its 
production  is  known  to  be  the  best,  during  four  months  of 
the  year  (June,  July,  August,  and  September).  Some 
dealers  sell  pasteurized  milk.  This  is  a  delusion  and  a 
snare,  as  it  has  been  clearly  shown  that  pasteurized  milk  is 
a  better  culture  medium  than  raw  milk.  Hence  the  home 
product  is  best,  as  it  is  not  kept  sufficiently  long  toi  be 
exposed  to  contamination. 

A  rough  method  of  pasteurization  applicable  to  cases 
wherein  expense  is  a  desideratum,,  that  is  efficient,  is  to  place 
the  milk  or  formula  into  a  sterilized  Mason  jar.  The  latter 
is  then  placed  into  a  vessel  containing  cold  water  which 
reaches  at  least  two-thirds  up  the  sides  of  the  jar.  The 
water  is  brought  to  the  boil,  at  which  time  it  is  removed 
from  the  fire,  the  lid  placed  upon  the  Mason  jar,  and  the 
whole  allowed  gradually  to  cool  off.  The  formula  is  now 
bottled.  In  summer  this  method  is  better  than  none  at  all, 
and  is  decidedly  superior  to'  sterilization,  since  the  tempera- 
ture of  the  milk,  while  rising  higher  than  when  using  the 
Freeman  apparatus,  is  considerably  less  than  the  boiling 


94  ARTIFICIAL   FEEDING. 

point, — a  fact  of  much  importance  if  the  process  is  to  be 
continued  over  a  long  period  of  time. 

Sterilization. — By  sterilization  is  meant  the  destruction 
of  germs  by  boiling.  It  may  or  may  not  include  the 
destruction  of  the  bacterial  toxins.  This  depends  upon  the 
character  of  the  toxin  and  its  power  to  resist  a  temperature 
of  212°  F.  Boiling  is  usually  continued  for  fifteen  to 
twenty  minutes.  It  is  a  fact  that  this  milk  can  be  kept  for 
many  months.  It  is  further  a  fact,  well  established  beyond 
dispute,  that  such  milk  fed  to  infants,  over  a  long  period 
of  time,  will  produce  scurvy  and  perhaps  rickets.  This  is 
due  to  the  chemical  changes  which  occur  in  the  milk.  The 
boiling  temperature  coagulates  the  lactalbumin  which  rises 
to  the  surface,  entangling  the  fat.  It  forms  the  so-called 
"skin"  of  boiled  milk.  Sterilized  milk  should  not  be  fed  to 
infants  ordinarily.  However,  in  some  cases  it  may  be  the 
choice  between  two  evils  as  a  temporary  measure.  Thus,  in 
the  summer  months,  it  may  be  the  safer  plan  to  tell  the  slum 
mother  to  boil  her  milk  before  feeding  it  to  her  infant,  than 
to  assume  the  risk  of  a  severe  intestinal  infection.  It  is 
further  borne  out  by  clinical  experience  that  boiling  the 
milk  for  a  short  period  (five  minutes)  greatly  assists  in 
rendering  the  curd  digestible. 

Pancreatized  Milk  or  Pancreatized  Formula. —  This  is 
sometimes  poorly  named  peptonized  milk.  Predigested 
milk,  which  is  synonymous,  is  a  better  term  than  the  latter. 
Dissolve  the  contents  of  one  of  Fairchild's  peptonizing  tubes 
in  i  ounce  of  water.  Add  this  to  a  pint  of  the  completed 
formula.  Mix.  Place  the  vessel  containing  this  in  water 
of  115°  F.  for  as  many  minutes  as  directed  to  do  so.  At 
the  end  of  the  required  time,  either  divide  into  the  number 
of  needed  bottles  and  place  at  once  on  ice,  or  bring  the 


METHODS    OF   MILK   ADAPTATION. 


95 


mixture  to  a  sudden  boil.  Either  method  will  stop  the  pan- 
creatization.  If  the  formula  or  milk  becomes  bitter,  the 
process  has  been  carried  too  far. 

Uses. — Pancreatized  milk  is  useful  in  cases  of  indiges- 
tion where  the  baby  cannot  digest  the  curd  or  fat  of  the 
milk.  It  does  well  in  some  cases  of  essential  marasmus. 


Fig.  18. — Apparatus  used  in  mixing  formula.  Pitcher,  16-02.  glass 
graduate,  sugar  measure,  large  spoon,  nursing  bottle,  glass  or  agate 
funnel,  corks.  (Physician's  Supply  Co.,  Phila,  Pa.) 

The  combination  of  i  teaspoonful  of  pulverized  flour  ball 
to  each  bottle  of  pancreatized  formula  often  forms  a  useful 
addition  in  curd  dyspepsia. 

How  to  Prepare  Formula. — The  preparation  of  the  for- 
mula in  the  home  must  be  done  with  care,  especially  with 
regard  to  cleanliness.  This  bears  reference  not  only  to  the 
proper  icing  of  the  milk,  but  to  everything  else,  including 
the  hands  of  the  nurse  or  mother,  all  utensils,  water  or 


96  ARTIFICIAL  FEEDING. 

diluents,  bottles  and  nipples  that  may  come  in  intimate  con- 
tact with  the  milk.  The  number  of  ounces  of  milk  or 
skimmed  milk  required  are  placed  in  a  large  sterile  pitcher 
made  of  glass  or  agate  (Fig.  18).  Into  this  is  measured, 
by  means  of  a  i6-ounce  glass  graduate,  the  required 
amount  of  diluent.  To  this  is  added  the  sugar,  salt,  or  any 
other  solid  ingredient  required.  A  druggist  will  furnish 
a  small  receptacle  or  box  marked  to  measure  an  ounce  of 


Fig.  19. — Nursing  bottle.  Fig.  20. — A  good  type  of  nipple. 

sugar  by  weight.  The  whole  is  thoroughly  mixed  with 
a  large  sterile  spoon.  It  is  now  placed  in  bottles  by 
means  of  a  glass,  agate,  or  tin  funnel,  previously  steril- 
ized. The  bottles  are  preferably  stoppered  with  sterile 
corks.  If  no  further  manipulation  is  required,  the  bottles 
are  well  iced  after  cooling,  and  placed  preferably  in  a  special 
nursery  refrigerator  (Fig.  23).  Under  no  circumstances 
are  they  permitted  td  come  in  contact  with  food.  If  it  be 
necessary  to  pasteurize,  while  in  the  pasteurizer  the  bottles 
must  be  closed  with  cotton  which  is  later  replaced  by  corks. 
Hygiene  of  the  Bottle  and  Nipple. — The  successful  feed- 
ing of  artificially  reared  infants,  aside  from  the  chemical 


METHODS   OF   MILK   ADAPTATION.  97 

composition  of  the  milk  mixture,  necessitates  the  strictest 
attention  to  details.  Of  these  the  selection  and  care  of  the 
nursing  bottle  and  nipple  are  matters  of  importance.  Gen- 
erally speaking,  that  bottle  and  nipple  are  the  best  which  are 
simplest  in  construction  and  are  the  most  easily  cleansed. 
Bottles  with  many  curves  and  angles  are  harmful.  The 
use  of  nursing  bottles  with  long  rubber  tubes  is  an  abomina- 
tion and  should  be  prohibited  by  law.  They  are  germ  car- 
riers, cannot  be  cleansed,  and  favor  decomposition  of  the 
milk.  The  best  bottle  is  oner  holding  about  6  or  8  ounces, 
and  which  consists  essentially  of  a  graduated  straight  tube, 


Fig.  21. — Bottle-brush.     (Physician's  Supply  Co.,  of  Phila.) 

tapering  slightly  as  it  reaches  the  top  (Fig.  19).  The 
bottle  should  be  thoroughly  cleansed  with  Castile  soap  and 
hot  water,  using  a  stiff  brush  (Fig.  21)  on  a  long  handle. 
It  is  then  thoroughly  rinsed  with  plain,  boiling  water  and 
filled  with  sterile  borax-water  when  not  in  use.  Before 
using,  it  is  again  thoroughly  scalded.  The  brush  used  to 
clean  the  bottle  must  also  be  sterile. 

The  best  nipples  are  those  which  allow  the  milk  to  flow 
easily  but  not  too  rapidly.  When  the  feeding  bottle  is  in- 
verted, the  milk  should  drop  from  the  nipple  and  not  run 
from  it  (Fig.  22).  Nipples  which  permit,  the  milk  to  flow 
rapidly  produce  colic.  Those  which  flow  too  slowly  may 
vex  and  irritate  the  infant.  One  of  the  best  nipples  is  known 
as  the  Mizpah.  The  Davidson  Health  nipple  is  also  a  good 


98  ARTIFICIAL  FEEDING. 

one  (Fig.  20).  Any  nipple)  which  is  simple  in  construction 
and  easily  cleansed  may  be  recommended.  The  nipples  made 
from  red  rubber  contain  lead,  therefore  only  the  black- 


Fig.  22. — Showing  correct  rapidity  of  flow  of 
formula  through  nipple.    . 

rubber  ones  are  to  be  employed.  A  nipple  should  not  be 
used  longer  than  a  week,  as  the  rubber  becomes  poor  and  is 
not  easily  sterilized.  The  same  treatment  should  be 
accorded  the  nipples  as  the  bottles,  except  that  they  should 


METHODS    OF    MILK   ADAPTATION. 


99 


not  be  boiled.  They  are  turned  inside  out  and  well 
scrubbed  with  Castile  soap  and  hot  water.  Afterward  they 
are  rinsed  in  hot,  sterile  water.  When  not  in  use  they  are 
kept  in  a  solution  of  sterile  borax-water  or  boric  acid  solu- 
tion. Immediately  before  use  they  are  immersed  in  sterile 
water.  Blind  nipples  are  purchaseable  and  are  convenient 


Fig.  23. — Nursery  refrigerator.     (Courtesy  of  Gimbel 
Bros.,  Phila.) 

when  it  is  impossible  to  secure  nipples  with  sufficiently 
small  holes.  The  latter  are  made  by  passing  a  fine,  red-hot 
needle  through  the  apex  of  the  nipple.  A  great  incon- 
venience, difficult  to  overcome,  is  the  collapse  of  the  nipple 
while  the  infant  is  sucking.  In  order  to  obviate  this,  a 
nipple  and  bottle  called  the  Novae  have  been  placed  on  the 
market  and  are  of  some  value. 

Diet-kitchen;  Refrigerator. — If  available,  a  small  room 
especially  set  aside  as  a  diet-kitchen,   devoted  entirely  to 


100  ARTIFICIAL   FEEDING. 

the  preparation  of  the  infant's  food,  is  desirable.  In  hos- 
pitals this  is  essential.  Among  the  poor,  however,  the 
physician,  if  he  will  but  interest  himself,  can  do1  much  to 
improve  the  hygienic  surroundings,  so  that  the  preparation 
of  the  food  may  be  accomplished  with  safety.  Ice  is  essen- 
tial to  the  preservation  of  the  formula.  A  very  convenient 
and  hygienic  arrangement  is  the  nursery  refrigerator,  to 
which  reference  has  already  been  made  (Fig.  23).  These 
refrigerators  come  in  two  sizes  and  may  be  purchased  for 
from  $1.50  to  $3.00.  The  sides  are  packed  with  mineral 
wool.  They  are  divided  into  two  compartments,  one  in 
which  the  bottles  may  be  kept  surrounded  with  ice  and 
another  in  which  such  things  as  the  milk,  barley-water,  and 
beef-juice  may  be  kept.  Icing  the  milk  or  formula  is  a 
serious  problem  with  the  poor  and  ignorant,  especially 
during  hot  weather.  Very  often  a  bottle  half-finished  will 
be  permitted  to  lie  around  for  several  hours,  to  be  again 
offered  to  the  infant.  This  practice  is  exceedingly  danger- 
ous and  must  be  prevented. 

How  to  Tell  when  Formula  Agrees. — The  best  evidence 
that  the  proper  food  has  been  selected  for  the  infant  is  fur- 
nished by  the  condition  of  its  digestion  and  its  weekly 
weight  record.  The  stools  may  not  at  once  become  normal. 
The  change  is  usually  gradual.  Too  frequent  alterations 
in  the  composition  of  the  food  are  not  to  be  made.  The 
individual  digestive  apparatus  must  be  given  an  opportunity 
to  become  accustomed  to  the  new  food.  This  only  applies 
to  minor  disturbances.  Severe  gastrointestinal  derange- 
ments call  for  radical  changes.  A  gain  of  from  5'  to  7 
ounces  a  week  is  normal.  Less  than  this,  in  the  beginning 
of  the  use  of  a  new  food,  until  the  proper  strength  is  reached 
is  satisfactory.  The  infant's  disposition  while  awake,  and 


METHODS    OF   MILK   ADAPTATION.  101 

its  ability  to  secure  a  proper  amount  of  sleep,  are  first-hand 
guides  as  to  the  success  of  the  feeding,  unless  the  baby  be 
hampered  and  viciously  trained. 

Feeding  Routine ;  Amounts  to  be  Fed ;  Feeding  Interval ; 
Diurnal  Feeding ;  Nocturnal  Feeding. — No  fixed  rule  can  or 
should  be  given.  The  demands  of  the  individual  must  be 
met.  As  the  student  requires  some  guide  upon  which  to 
base  his  original  advice  which  may  be  adjusted  by  future 
observation,  the  following,  as  representing  the  result  of 
practical  experience,  is  suggested.  Up  to  6  months  the 
number  of  ounces  of  each  feeding  may  approximately  be 
representel  by  the  infant's  age  expressed  in  months.  After 
this  the  progression  is  somewhat  slower,  s&  that  at  i  year 
it  receives  about  10  ounces. 

The  feeding  interval  should  be  every  two  hours  until 
after  3  months,  with  two  night  feedings  after  midnight. 
The  infant  is  to  be  awakened  regularly  for  its  meals  during 
the  day  on  the  exact  feeding  hour,  timing  from  the  com- 
mencement of  the  last  meal  and  not  from,  the  finish.  Be- 
fore feeding,  the  food  is  to  be  properly  warmed  by  im- 
mersing the  bottle  in  hot  water.  The  formula  will  be  of  the 
proper  temperature  when  it  can  be  comfortably  dropped 
upon  the  back  of  the  hand.  The  bottle  must  be  held  for 
very  young  infants.  The  infant  is  not  permitted  to  suck 
air.  The  neck  of  the  bottle  is  always  kept  full.  The  infant 
may  not  sleep  with  the  nipple  in  its  mouth.  The  meal 
should  be  finished  within  from  fifteen  to  twenty-five 
minutes.  The  food  must  not  be  given  too  rapidly.  This 
may  be  guarded  against  by  having  a  nipple  which  does  not 
permit  too  rapid  a  flow,  and  by  removing  the  nipple  from 
the  infant's  mouth  at  the  end  of  every  third  or  fourth  suck. 
The  meal  should  be  given  with  the  infant  lying  down. 


102 


ARTIFICIAL   FEEDING. 


After  feeding,  its  mouth  is  gently  cleansed!  with  boric  acid 
solution  and  the  infant  must  not  be  picked  up.  From  the 
third  to  the  end  of  the  sixth  month  the  feeding  interval  is 
lengthened  to  two  and  one-half  hours ;  from  the  seventh  to 
the  end  of  the  ninth  month,  every  three  hours;  from'  this 
time  to  12  months,  every  three  and  one-half  hours. 

After  the  fourth  month,  and  sooner  if  feasible,  no  night 
feedings  are  to  be  given  unless  under  exceptional  circum- 
stances. (See  Vomiting,  Chapter  VII.)  The  adoption  of 
some  such  routine  has  an  excellent  effect  upon  the  patient's 
nervous  development  and  its  digestion.  Good  feeding 
habits  are  as  easy  to  inculcate  as  vicious  ones,  and  make 
for  the  comfort  of  the  infant  and  the  general  good  morale 
of  the  entire  household.  The  infant  should,  if  possible,  be 
in  a  room  by  itself  and  left  immediately  as  soon  as  its  meal 
is  finished  and  its  general  wants  attended.  Soon  it  will  be 
found  that  the  baby  will  respond  to  this  scheme  of  regularity. 
It  may  take  a  week  or  more  to  accustom  some  infants  to  it, 
but  the  trial  is  worth  the  effort  on  account  of  the  future 
comfort  which  ensues. 

FEEDING  TABLE. 


Age. 

Amounts  to 
be  fed. 

Feeding 
interval. 

Daily 
quantity. 

Night 
feedings. 

Up  to    3      weeks 

i      to  2      oz. 

2      hours 

n  to  22  oz. 

2 

Up  to    2d    month 

2^2  td  3      oz. 

2      hours 

25  to  33  oz. 

2 

Up  to  end  of  3d  m. 

3      to  $y2  oz. 

2      hours 

25  to  35  oz. 

I 

During  4th  month 

4      to  5       oz. 

2l/2  hours 

32  to  40  oz. 

I 

During  5th  month 

S      to  6      oz. 

2l/2  hours 

35  to  42  oz. 

0 

Up  to  end  of  6th  m. 

6      to  7      oz. 

2l/2  hours 

42  to  45  oz. 

O 

During  7th  month 

7      to  8      oz. 

3      hours 

42  to  48  oz. 

o 

During  8th  month 

7      to  8      oz. 

3      hours 

42  to  48  oz. 

0 

Up  to  end  of  9th  m. 

8      to  9      oz. 

3      hours" 

45  to  50  oz. 

0 

During  loth  month 

9      oz. 

3Y2  hours 

45  to  50  oz. 

0 

During  nth  month 

9      oz. 

3*/2  hours 

50  to  55  oz. 

o 

Up  to  end  of  I2th  m. 

10      oz. 

3^  hours 

50  to  55  oz. 

0 

METHODS    OF   MILK   ADAPTATION.  103 

Individual  peculiarities  or  digestive  disturbances  may 
necessitate  a  radical  change  in  the  feeding  routine  as  to 
feeding  interval  and  qwwtity  to  be  fed.  No  absolute  routine 
may  be  prescribed  for  all  babies.  Here  as  elsewhere  in- 
dividualization  must  be  the  basic  keynote  of  practice.  Thus 
the  advocates  of  a  regular  four-hour  interval  may  be  as 
dogmatic  as  they  desire  to  be  regarded  as  progressive. 
Reference  to  the  indications  for  shorter  or  longer  intervals 
and  for  larger  or  smaller  amounts  to  be  fed  will  be  found 
in  their  proper  place -with  in  the  body  of  the  text. 

Bottle  Feeding  Among  the  Poor.  Milk  Stations. — 
Among  the  poor,  the  artificial  feeding  of  infants  who  are 
deprived  of  breast  milk,  is  a  problem  that  touches  the  ques- 
tion of  infant  mortality  and  concerns  the  State  as  well  as 
the  individual.  Economic  conditions  underlie  the  entire  sit- 
uation. The  conservation  of  the  human  milk-supply  is  vital, 
and  it  does  not  seem  to  be  Utopian  to  express  the  hope 
that  the  nursing  mother  of  the  poor  may  some  day  become 
the  ward  of  the  State  during  the  lactating  period,  or  be  paid 
outright  for  her  services  in  nursing  an  infant  so  that  she 
may  be  relieved  of  all  other  material  responsibility  during 
this  time. 

Where  the  infant  is  artificially  reared,  accurate  adjust- 
ment to  the  individual's  digestive  peculiarities  is  just  as 
possible,  with  some  exceptions,  if  the  physician  takes  the 
trouble  to  teach  the  mother,  as  among  the  better  classes. 
The  greatest  difficulty  is,  however,  to  secure  pure  milk  at  a 
reasonable  price  and  to  keep  the  formula  properly  iced  until 
used.  Good  milk  cannot  be  secured  if  purchased  from  cans 
in  the  open  market.  For  this  reason  milk  stations  have  been 
established  to  provide  it  at  cost  or,  in  worthy  cases,  free. 
These  milk  stations,  in  conjunction  with  the  visiting  nurses, 


104  ARTIFICIAL  FEEDING. 

have  accomplished  much  in  the  reduction  of  infant  mortality. 
It  appears,  however,  to  be  a  useless  expenditure  of  funds 
where  much  more  good  could  be  done  by  sustaining  the 
mother  during  the  nursing  period,  as  previously  stated. 
Pasteurization  if  feasible  and,  if  not,  sterilization  should  be 
practised  during  the  summer  months.  The  latter  is  easier 
and  more  certain,  and  should  always  be  advised  without 
thought  as  to  the  future  development  of  scurvy.  This  may 
be  combated  by  the  simultaneous  administration  of  fruit- 
juices. 

Condensed  milk,  being  sterile,  is  a  valuable  makeshift 
when  added  to  boiled  water,  and  may  be  successfully  used 
in  many  instances  throughout  the  summer  months. 

Feeding  while  Travelling. — If  the  journey  be  short,  occu- 
pying twenty-four  hours  or  less,  a  day's  supply  of  a  formula 
may  be  prepared  and  placed  in  a  sterilized  Thermos  bottle, 
or  be  bottled  and  put  into  a  small  receptacle,  as  a  bucket,  and 
properly  iced.  Where  a  journey  of  some  distance  is  to  be 
taken,  as  a  sea-voyage,  reliance  may  confidently  be  placed 
upon  condensed  milk  or  Ramogen. 

THE  DIGESTIVE  DISTURBANCES  OF  THE  BOTTLE-FED 
AND  HOW  TO  TREAT  THEM. 

Pediatrists  are  agreed  as  to  the  frequency  of  the  diges- 
tive disturbances  of  the  artificially  reared,  as  well  as  to  the 
serious  and  often  fatal  effects  these  may  have  upon  the 
nutrition  of  the  infant.  Difference  of  opinion,  however, 
exists  as  to  the  etiologic  basis  of  these  digestive  upsets. 
The  controversy  as  to  which  of  the  food  elements,  fats,  pro- 
tein, or  sugar,  of  cows'  milk,  is  responsible  still  continues, 
although  the  German  contention,  that  most  of  the  trouble 
depends  upon  a  relative  excess  (for  the  individual)  of  fats 


PLATE  VIII 


Hard,  dry.  whitish,  constipated,  crumbly  stool,  consisting  of  undi- 
gested protein,  occurring  in  a  bottle-fed  baby.  These  movements  are 
passed  with  much  straining.  (See  text  for  treatment  of  protein  intol- 
erance.) 


DIGESTIVE  DISTURBANCES  OF  BOTTLE-FED.         105 

and  sugar,  and  rarely  upon  a  relative  excess  of  protein, 
seems  to  possess  at  the  present  time  the  predominant  influ- 
ence upon  the  medical  mind.  An  active  feeding  experience 
of  fifteen  years  does  not  permit  entire  accord  with  this 
view.  It  is  patent  that  the  feeding  of  an  excessive  relative 
amount  of  any  or  all  of  the  food  elements  may  cause  trouble, 
but  the  attempt  to  harness  the  responsibility  upon  one  or 
more  to  the  exclusion  of  the  rest  appears  dogmatic  and  futile. 
The  researches  of  von  Pirquet  clearly  demonstrate  that  the 
infant  thrives  best  when  fed  the  food  optimum  (an  amount 
just  within  the  limit  of  the  greatest  quantity  of  food  that  the 
organism  can  assimilate,  i.e.,  the  limit  of  food  tolerance), 
and  that  loss  of  weight  results  from  exceeding  the  food 
maximum  as  quickly  as  when  the  infant  receives  less  than 
the  minimum.  In  the  second  instance  the  loss  of  weight 
occurs  because  the  food  tolerance  becomes  lowered  from 
the  burden  placed  upon  the  digestive  apparatus.  Conse- 
quently assimilation  becomes  poor  and  the  infant  is  prac- 
tically in  the  same  position  as  if  he  were  receiving  less  than 
the  minimum.  He  starves  from  overfeeding  because  non- 
digestion  means  non-assimilation.  In  the  last  instance 
weight  falls  because  not  enough  nourishment  is  provided. 
The  digestive  organs,  however,  having  been  given  a  chance 
to  rest,  the  limit  of  food  tolerance  is  increased  as  evidenced 
by  our  ability  to  gradually  increase  the  strength  and  amount 
of  the  food.  Reference  will  again  be  made  to  this  fact. 
Thus,  while  these  statements,  based  upon  von  Pirquet's 
work,  indicate  that  the  digestive  disturbances  depend  upon 
the  fact  that  the  food  maximum  has  been  exceeded,  they 
do  not  mean  that  any  one  particular  ingredient  is  respon- 
sible in  all  instances.  A  clinical  fact  of  importance  is  that 
it  is  often  possible  to  feed  large  relative  amounts  of  one 


106  ARTIFICIAL  FEEDING. 

food  element  while,  if  all  are  relatively  large,  trouble  will 
ensue.  Thus,  a  high  fat  may  be  tolerated  when  fed  alone, 
but  when  exhibited  with  a  high  protein  or  a  high  sugar,  or 
both,  may  be  responsible  for  fat  indigestion. 

To  exclude  proteins  as  an  etiologic  factor  of  indigestion 
is  a  fallacy.  Cases  of  this  type  do  occur  and  are  marked  by 
definite  symptoms.  They  are  as  common  today  as  they 
were  ten  years  ago,  when,  to  the  exclusion  especially  of 
sugar,  nearly  all  digestive  disturbances  were  laid  at  the  door 
of  this  element.  All  so-called  present-day  curds  in  the  stools 
are  not  fat.  Clinical  experience,  very  frequently,  in  spite 
of  the  researches  of  modern  investigators,  recognizes  them 
as  calcium  paracasein,  and  they  may  be  readily  demon- 
strated to  be  protein  by  the  xanthoproteic  test.  It  is  as 
impossible  today  to  feed  relatively  or  absolutely  as  high 
percentages  of  chemically  or  mechanically  unmodified  cow- 
curds  as  it  was  years  ago,  and  to  teach  otherwise  is  danger- 
ous and  cannot  but  lead  to  disaster. 

PROTEIN  INDIGESTION  OR  INTOLERANCE. 
When  an  excess — and  by  excess  is  meant  an  excess  for 
the  individual,  which  in  reality  may  be  a  small  amount — of 
protein  is  fed  to  an  infant,  tolerance  may  persist  for  a  brief 
period,  to  be  followed  by  digestive  disturbances  and  inter- 
ference with  the  nutrition.  Protein  excess  is  rarely  marked 
by  vomiting  unless  the  amount  be  so  large  that  its  speedy 
coagulation  is  followed  by  ejection  from  the  stomach  in  the 
form  of  a  tough,  leathery  mass  within  a  short  time  after 
feeding.  The  main  features  of  disturbance  are  confined  to 
the  intestinal  tract.  The  stools  are  usually  loose  and  green 
(Plate  V).  They  have  an  unpleasant,  but  rarely  foul 
odor,  and  contain  considerable  mucus  and  white  or 


PROTEIN   INDIGESTION   OR   INTOLERANCE.         107 

whitish-yellow  masses  of  undigested  calcium  paracasein 
(curd).  These  masses  may  exist  in  an  otherwise  normal 
stool.  This  is  not  indigestion,  but  non-digestion  of  rela- 
tively too  much  curd.  In  this  instance  the  curds  act  as  a 
foreign  body,  and  if  their  presence  persists  they  may  cause 
serious  intestinal  irritation.  These  symptoms  resemble  the 
dyspepsia  of  Finkelstein,  described  by  him  as  due  to  exces- 
sive fat  or  sugar.  As  before  stated,  the  masses  may  be  dis- 
tinguished as  being  protein  by  the  xanthoproteic  test.  The 
babies  have  colic  and  are  very  irritable. 

In  other  instances,  where  too  much  protein  is  being 
fed,  constipation  exists,  and  the  movements  are  hard,  whitish, 
dry,  and  readily  crumble  (Plate  VIII).  They  are  passed 
with  considerable  effort,  as  a  single  mass  covered  with 
mucus,  which  may  be  blood-stained.  Stationary  weight  or 
a  loss  is  recorded  in  both  these  types  of  protein  intolerance. 
The  urine  is  often  scanty,  highly  acid,  and  deposits  of  uric 
acid  and  urates  are  noted  on  the  diaper.  The  temperature 
range  in  these  cases  is  between  99°  F.  and  100^2°  F.  or 
may  be  normal. 

Treatment. — An  initial  purgative  of  from  I  to  2  drams 
of  castor  oil  should  be  given.  An  excellent  substitute  con- 
sists of  equal  parts  of  castor  oil  and  the  aromatic  syrup  of 
rhubarb.  Of  this  substance  double  the  dose  just  indicated 
is  to  be  prescribed.  Initial  purgation  is  followed  by  barley- 
water  or  whey  feeding  for  twenty-four  to  forty-eight  hours, 
or  by  weak  tea  sweetened  with  saccharin.  In  protein  intol- 
erance initial  purgation  is  valuable  and  without  danger. 
(See  "Diarrhea,"  Chapter  IX,  page  267.)  Whey  is 
practically  a  5  per  cent,  solution  of  milk-sugar  containing 
i  per  cent,  of  fat  and  i  per  cent,  of  soluble  proteins.  To 
the  whey,  properly  heated  to  150°  F.  in  order  to  destroy 


108  ARTIFICIAL   FEEDING. 

any  remaining  ferment,  may  now  be  gradually  added  small 
amounts  of  plain  milk  or  cream  (split  proteins).  These,  as 
tolerance  is  established,  may  be  cautiously  increased. 

In  mild  cases  it  may  be  unnecessary  to  entirely  eliminate 
the  coagulable  protein  by  whey  feeding,1  or  whey  feed- 
ing may  not  be  continued  long,  a  gradual  return  being  made 
to  the  formula,  starting  with  a  weak  mixture  and  gradually 
increasing.  In  this  case  it  is  advisable,  for  a  short  period 
at  least,  to  pancreatize  the  formula  (page  94).  The  time 
of  pancreatization  is  gradually  reduced  and  finally  it  is 
entirely  omitted.  After  this  the  addition  of  some  efficient 
digestive  ferment  to  each  bottle,  just  before  feeding,  is  an 
excellent  aid  until  the  digestive  function  has  been  completely 
re-established. 

The  early  teaching  of  Jacobi1  advocating  the  use  of 
cereal  decoctions  still  holds  good  as  an  excellent  means  of 
rendering  the  paracasein  easily  digestible,  and  has  received 
more  recent  emphasis  from  the  work  of  Chapin,  who  em- 
ploys dextrinized  gruels  (page  86).  The  cereal  decoctions 
provide  a  certain  amount  of  starch,  which,  according  to  the 
investigations  of  Kerley,2  can  be  digested  and  assimilated 
by  infants  as  young  as  19  days. 

Ordinarily  barley-water  made  from  the  grain  is  to  be 
preferred,  either  full  strength  or  diluted  one-half  with  boiled 
water.  If  constipation  be  present,  oatmeal-water  makes  an 
excellent  substitute.  In  this  connection  the  old-fashioned 
flour  ball  has  rendered  excellent  service.  It  may  be  baked 
to  a  bread  brown  and,  after  being  pulverized  and  sifted, 
added  to  each  bottle  just  before  feeding.  At  the  same 
time  a  few  grains  of  the  very  best  extract  of  pancreatin 

1  Jacobi,  A.,  "Therapeutics  of  Infancy  and  Childhood,"  p.  29. 

2  Kerley,  C.  G.,  "The  Treatment  of  Diseases  of  Children,"  p.  126. 


PROTEIN   INDIGESTION   OR  INTOLERANCE.         109 

may  or  may  not  be  employed.  If  the  pancreatin  is  not 
pure,  the  stools  may  become  foul.  Flour  ball  may  also  be 
used  as  follows:  2^2  to  5  per  cent,  of  the  total  quantity  of 
milk  mixture  is  made  to  represent  the  amount  of  flour  ball 
used.  To  this  may  be  added  5  to  10  grains  of  pure  pan- 
creatin, or  the  pancreatin  may  be  omitted.  A  portion  of  the 
completed  formula  is  rubbed  while  cold  with  the  flour  ball 
so  that. a  smooth  paste  results.  The  remainder  of  the  for- 
mula is  brought  just  to  the  boiling  point  in  a  double  boiler. 
It  is  poured  over  the  moistened  flour  ball  and,  if  pancreatin 
has  been  added,  it  is  maintained  at  this  temperature  for 
fifteen  minutes,  when  the  mixture  is  again  raised!  to  the 
boiling  point,  allowed  toi  cool,  and  is  bottled  and  iced.  If 
no  pancreatin  has  been  added,  immediately  after  adding  the 
hot  formula  it  is  allowed  to  cool  and  iced  without  the 
second  heating.  The  use  of  flour  ball  in  this  manner  is,  in 
the  vast  majority  of  cases,  immediately  followed  by  normal 
stools  and  a  progressive  gain  in  weight.  A  preparation  oin 
the  market  known  as  Benger's  Food  consists  practically  of 
pulverized  flour  ball  and  extract  of  pancreatin.  It  may  for 
convenience  be  employed  instead  of  the  home-made  flour 
ball.  It  gives  excellent  results  as  a  curd  modifier.  I  un- 
hesitatingly commit  the  heresy  of  recommending  it.  Both 
of  these  preparations  are  gradually  reduced  and  finally 
omitted. 

Sometimes  the  simple  boiling  of  the  formula  will  ren- 
der the  protein  digestible,  but  must  not  be  continued  too 
long  without  the  addition  of  fruit  and  animal  juices  to  the 
dietary. 

Sodium  citrate,  gr.  j  to  gr.  iij,  added  to  the  formula  for 
every  ounce  of  milk  and  cream  in  the  mixture,  may  render 
the  curd  digestible  by  causing  it  to  remain  fluid  until  it 


HO  ARTIFICIAL   FEEDING. 

reaches  the  small  intestine.  Its  effects  are  not  immediate 
and  are  usually  revealed  clinically  within  a  few  days.  It  is 
continued  for  some  weeks,  after  which  the  amount  is  grad- 
ually reduced. 

As  a  further  means  to  overcome  the  indigestibility  of 
protein,  the  use  of  mechanically  divided  curd  is  of  great 
service  and  permits  of  the  feeding  of  unusually  large 
amounts.  For  this  purpose,  buttermilk  and  eiweissmilch 
(pages  121  and  126),  especially  the  former,  serve  admirably 
as  temporary  foods  or  "pick  me  ups." 

As  already  mentioned,  Loeflund's  malt  soup  as  advo- 
cated by  Keller  is  of  service  in  removing  protein  masses 
from  the  stools  in  some  cases.  To  epitomize,  therefore, 
the  following  may  be  stated  as  the  means  of  dealing  with 
protein  intolerance: — 

1.  Eliminate  curd  by  whey  feeding. 

2.  Split  protein — whey  and  cream  or  whey  and  milk 
mixtures. 

3.  Pancreatization. 

4.  Cereal  decoctions — plain  or  dextrinized. 

5.  Flour  ball  alone  or  pancreatized. 

6.  Benger's  Food. 

7.  Plain  boiling. 

8.  Sodium  citrate. 

9.  Buttermilk. 

10.  Eiweissmilch. 

11.  Loeflund's  Malt  Soup. 

FAT  INDIGESTION  OR  INTOLERANCE. 

This,  by  Finkelstein,  has  been  designated  "weight  dis- 
turbance" when  occurring  in  its  milder  form.  When  of  a 
more  severe  type,  he  calls  it  "dyspepsia,"  the  symptoms  of 


FAT    INDIGESTION    OR   INTOLERANCE.  HI 

which  have  been  practically  described  as  protein  indigestion. 
No  two  babies  can  digest  the  same  amount  of  fat.  Diffi- 
culty is  therefore  experienced  in  attempting  to  arrange  any 
set  rule  for  the  proper  amounts  of  this  ingredient  to  be  fed. 
When  intolerance  occurs,  the  infant  commences  to  vomit. 
The  vomitus  is  sour,  smelling  like  rancid  butter,  and  occurs 
from  an  hour  to  an  hour  and  a  half  after  feeding.  The 
bowels  are  often  loose  and  just  as  often  constipated.  In 
the  former  instance  they  are  acid,  green,  or  green  and 
yellow,  and  greasy,  containing  mucus  and  lumps  of  un- 
digested fat,  that  may  be  mistaken  for  protein  curds 
(Plates  IV,  V,  and  VI).  These  "curds,"  or  masses,  are 
softer,  soluble  in  ether,  burn  when  dried,  are  blackened  by 
osmic  acid,  and  are  stained  characteristically  by  Sudan  III. 
The  addition  of  a  solution  of  Sudan  III  causes  the  fat  par- 
ticles and  oil  globules  to  appear  red  under  the  microscope. 
When  placed  in  water,  oil  droplets  are  found  floating  on 
the  surface. 

When  constipation  occurs,  typical  soap  stools  (Plate 
VII)  are  found.  The  constipated  stools  are  quite  often 
solid,  greasy,  foul-smelling,  and  whitish  or  grayish  white, 
or  they  may  have  a  pinkish  tinge  (Plate  VI).  They  fre- 
quently contain  large  or  small  granular  masses  of  hard 
calcium  soap,  sometimes  covered  with  mucus  which  may  be 
blood-tinged  (Plate  VII).  These  stools  result  from  the 
formation  of  fatty  acids  in  the  stomach  and  intestines. 
These  acids  combine,'  with  the  mineral  substances  of  the 
body  and  intestinal  mucus.  Thus  a  process  of  deminerali- 
zation  obtains.  The  direct  result  of  this  is  a  profound  effect 
upon  the  whole  nutrition.  The  weight  remains  stationary 
or  a  slight  loss  is  noted.  The  infant  becomes  anemic,  weak, 
and  the  bones  commence  to  show  evidences  of  poor 


112  ARTIFICIAL  FEEDING. 

ossification,  and  enlargement  of  the  epiphyseal  junctions 
(incipient  rickets). 

The  urine,  on  account  of  the  large  excess  of  fatty 
acids  entering  the  blood  and  being  there  neutralized,  be- 
comes highly  alkaline  and  emits  a  decided  ammoniacal 
odor.  If  this  condition  of  acidosis  continues,  the  digestive 
processes  are  all  disturbed  and  intolerance  for  all  food  may 
ensue,  to  be  followed  by  marasmus  or  decomposition 
(Finkelstein).  As  a  rule  the  temperature  remains  normal 
or  is  only  slightly  elevated  at  times. 

Treatment. — An  initial  purgative  of  castor  oil  may  or 
may  not  be  valuable,  depending  upon  the  severity  of  the 
symptoms.  In  mild  cases  it  should  be  withheld  ("Diarrhea," 
Chapter  IX,  page  267.  The  temporary  course  of  barley- 
water  or  whey  feeding  may  be  of  service.  However,  where 
the  diagnosis  is  certain,  all  fat  had  better  be  at  once 
eliminated  following  a  period  of  starvation.  This  is  accom- 
plished by  the  use  of  dilutions  of  fat-free  milk  (completely 
skimmed  milk).  These  may  be  made  half  and  half,  or, 
better,  i  part  of  milk  and  3  of  water.  Gradually,  as 
tolerance  is  established,  the  dilution  is  made  less  and 
finally  small  quantities  of  cream  may  be  added,  or  plain 
whole  milk  may  be  fed,  at  first  well  diluted.  From  2^ 
to  5  per  cent,  of  extra  carbohydrate  (sugar)  is  added.  The 
fat  is  gradually  increased,  keeping  well  within  the  border  of 
tolerance.  . 

Where  great  acidity  exists,  marked  by  sour  eructations, 
alkaline  urine  and  soap  stools,  lime-water  in  quantities 
ranging  from  5  to  25  per  cent,  should  be  added  to  all 
formulas.  This  seeks  to  prevent  alkalinization  of  the  fatty 
acids  by  the  tissues  of  the  body,  thereby  preventing  de- 
mineralization  and  acidosis.  Fresh  buttermilk  forms  an 


SUGAR   INDIGESTION    OR   INTOLERANCE.  113 

excellent  substitute  in  fat  intolerance.  If  made  at  home 
by  the  simple  addition  of  lactic  acid  tablets,  all  cream  should 
have  been  at  first  removed.  The  deficiency  of  caloric  value, 
as  the  result  of  this,  is  made  up  by  the  addition  of  cane- 
sugar  and  wheat-flour  in  gradually  increasing  quantity 
(Chapter  III,  page  123). 

Pancreatization  may  overcome  fat  intolerance  without 
necessitating  a  great  reduction  in  the  amount  of  fat  fed. 
It  must  not  be  continued  too  long,  or  the  very  purpose  for 
which  it  was  used  will  be  defeated. 

SUGAR  INDIGESTION  OR  INTOLERANCE. 

Sugar  has  come  into  prominence  as  a  great,  if  not  the 
greatest,  factor  in  the  digestive  disturbances  of  infancy. 
For  reasons  previously  stated,  personal  experience  does  not 
permit  of  entire  accord  with  this  view.  It  has  rarely  been 
a  source  of  trouble.  The  reason  for  this  may  be  that 
routinely,  following  the  teachings  of  Jacobi,  cane-sugar, 
instead  of  the  commercially  impure  lactose,  has  been  em- 
ployed. Frequent,  watery,  acid  stools  that  excoriate  the 
buttocks,  associated  with  a  sour,  watery  vomitus  which 
irritates  the  esophagus  and  causes  the  infant  to  cry,  together 
with  flatulency  and  colic,  are  indicative  of  sugar  indiges- 
tion. The  urine  may  contain  sugar;  the  baby  may  develop 
a  high  temperature  and  pass  into  a  state  of  collapse  on 
account  of  the  frequent  evacuations.  A  rapid  loss  of 
weight  occurs, — intoxication  (Finkelstein). 

There  are  some  infants  who  receive  an  excess  of  sugar 
and  who  do  not  suffer  from  indigestion,  but  grow  fat. 
They  are.  however,  flabby,  anemic,  and  often  develop 
rickets  and  scurvy  at  the  same  time,  being  subject  to  colds 
and  to  eczematotis  rashes. 


114  ARTIFICIAL  FEEDING. 

Treatment — If  the  condition  be  acute  and  the  symp- 
toms of  intoxication  severe,  castor  oil  and  starvation  for 
twenty-four  hours  are  indicated.  In  mild  cases  initial  pur- 
gation is  unnecessary  and  does  harm.  During  this  time 
cereal-waters  or  weak  tea  sweetened  with  saccharin,  gr.  j 
to  the  quart,  are  employed.  If  not  acute,  this  preliminary 
treatment  may  be  omitted.  In  this  condition  Finkelstein's 
eiweissmilch  finds  its  greatest  field  of  usefulness.  It  is, 
unfortunately,  very  difficult  to  prepare,  except  in  institu- 
tions, and  hence  may  be  impracticable.  A  good  substitute 
consists  of  equal  parts  of  buttermilk  and  of  a  wheat-flour 
solution  (Chapter  III,  page  123).  Both  this  and  the 
eiweissmilch  may  be  sweetened  with  saccharin,  gr.  j  to  the 
quart.  The  infant  may  be  kept  upon  the  buttermilk  mix- 
ture for  some  time,  and  will  gain,  especially  if  gradually 
increasing  amounts  of  cane-sugar  or  Dextri-Maltose  are 
added. 

As  far  as  the  addition  of  extra  carbohydrates  to  milk 
formulas  is  concerned,  increasing  experience  with  it  seems 
to  demonstrate  the  value  of  maltose.  This  is  found  on 
the  market  as  Mead-Johnson's  Dextri-Maltose  or  as 
Loeflund's  Food  Maltose.  Both  are  mixtures  of  dextrin 
and  maltose.  The  latter  is  the  more  expensive,  as  it  is  an 
imported  product.  Both  are  used  in  the  same  manner  as 
cane-sugar  or  lactose.  A  similar  preparation  is  Soxhlet's 
Nahrzucker. 

Normal  breast  and  bottle  stools  are  shown  in  Plates 
II  and  III. 

DEFICIENCY  OF  FOOD  ELEMENTS. 

This  is  marked  by  slow  growth,  stationary  or  losing 
weight,  irritability,  and  usually  by  a  subnormal  temperature, 


FOOD    IN    IMPROPER   QUANTITIES.  115 

unless  the  point  of  starvation  is  reached,  when  fever  may 
occur.  Constipation  is  the  rule  and  the  stools  are  normal 
in  appearance,  but  of  small  bulk.  Deficiency  of  food  ele- 
ments may  not  mean  deficient  bulk.  In  fact,  this  most  often 
is  excessive,  but  then  the  milk  mixture  is  weak.  It  must  be 
remembered  that,  aside  from  the  characteristic  digestive 
disturbances,  the  same  features  of  nutritional  impairment 
may  be  brought  about  by  unduly  strong  mixtures,  the 
excess  causing  digestive  disturbances  which  may}  prevent 
proper  assimilation.  The  patient  actually  receives  a  defi- 
ciency of  all  the  elements.  Rickets  and  scurvy  may  follow 
a  deficiency  in  fat,  protein,  and  mineral  substances. 

FOOD  IN  IMPROPER  QUANTITIES. 

The  average  quantities  of  food  have  been  stated  pre- 
viously (page  102).  A  formula  may  be  suitable  to  the 
digestion  of  an  individual,  and  yet  be  fed  to  him  too  fre- 
quently and  in  too  large  amounts.  This  is  just  as  often 
the  cause  of  digestive  disturbances  as  excessive  amounts  of 
any  special  ingredient.  It  is  noted  in  breast-fed  children 
who  are  nursed  every  time  they  cry.  These  babies  are 
always  irritable,  vomit,  have  bad  bowels,  and  often  lose 
weight.  This  is  true,  especially  of  bottle  babies. 

On  the  other  hand,  insufficient  amounts  of  a  correct 
formula  may  be  given.  These  babies  are  always  irritable, 
do  not  rest  well,  and,  immediately  after  receiving  the  bottle, 
are  unsatisfied,  cry,  and  do  not  fall  asleep  at  once  as  most 
babies  do*.  They  usually  have  a  stationary  weight  or  lose 
a  few  ounces.  Increase  in  the  quantity  of  the  food  is  im- 
mediately followed  by  a  gain  in  weight. 


116  ARTIFICIAL   FEEDING. 

FEEDING  OF  DELICATE  AND  SICK  INFANTS. 

That  this  is  a  difficult  problem  gives  no  information, 
and  yet  in  the  handling  of  delicate  babies  who  are  not  act- 
ually ill,  but  only  below  par,  general  rules  may  be  given  to 
be  applied  to  the  individual  case  as  the  indications  demand. 
The  digestion  of  these  infants  must  be  carefully  watched, 
and  at  the  first  sign  of  trouble  it  is  wise  to  immediately 
lessen  the  strength  and  quantity  of  the  formula,  or,  perhaps, 
withdraw  it  entirely  for  twenty-four  hours.  Not  a  bad 
practice  is  to  have  the  mother  make  the  formula  as  here- 
tofore, but  just  before  feeding  to  pour  out  of  the  bottle 
one-half  or  three-fourths  or  one-fourth  and  replace  it  by 
water.  A  gradual  return  is  then  made  to  the  full  strength. 
Quantities  to  be  fed  must  be  regulated  according  to  the 
tolerance  of  the  stomach  and  the  appetite.  While  it  is 
desirable  to  give  the  stomach  absolute  rest,  many  cases  do 
better  when  fed  small  amounts  frequently.  Here  the  peculi- 
arities of  the  individual  case  must  be  studied. 

Infants  sick,  of  diseases  other  than  those  depending 
upon  feeding  or  disorders  of  the  stomach  and  intestines, 
must  have  their  food  carefully  watched,  as  they  are  excep- 
tionally prone  to  digestive  upsets.  Such  an  event  may  be 
the  cause  of  a  fatal  outcome.  In  no  disease  is  this  better 
illustrated  than  in  pneumonia,  wherein  an  extensive  and 
persistent  tympanites  often  closes  the  issue.  In  acute  illness 
food  should  be  withdrawn  for  twenty-four  hours,  and  a 
return  to  the  original  strength  not  be  made  until  after  the 
crisis,  or  the  main  symptoms  have  subsided.  If  digestion  is 
sluggish,  the  formula  should  be  pancreatized  and  fed  in 
small  amounts.  Overfeeding  should  never  be  permitted, 
and  the  infant  is  not  to  be  disturbed  too  frequently,  either 


FEEDING    DELICATE   AND    SICK   INFANTS.  117 

for  food,  medicine,  or  other  attention.  It  is  frequently 
advisable,  when  gastrointestinal  symptoms  arise,  to  with- 
draw milk  altogether  during  the  entire  course  of  the  illness, 
and  keep  the  patient  upon  animal  broths  or  juices,  alone 
or  in  combination  with  cereal  decoctions,  thin  gruels,  or 
albumin-water.  For  a  more  detailed  description  of  this 
topic  see  Chapter  XIII. 


CHAPTER  III. 

ARTIFICIAL  FEEDING. 

(Continued.) 


IDIOSYNCRASY  TO  COWS'  MILK. 

THIS  is  an  actual  condition.  The  smallest  amount  of 
cows'  milk  may,  in  susceptible  individuals,  cause  symptoms 
of  gastrointestinal  derangement,  sometimes  accompanied  by 
skin  rashes.  Though  rare,  the  physician  should  be  suffi- 
ciently familiar  with  the  symptoms  to  recognize  them. 
Kerley  has  reported  a  case.  The  history  of  the  following 
case  is  of  sufficient  interest  to  warrant  a  somewhat  detailed 
report :  This  was  a  healthy  infant,  nursed  from  the  begin- 
ning by  a  wet-nurse.  The  fat  in  the  nurse's  milk  ran  as 
high  as  8  per  cent.,  causing  frequent  attacks  of  fat  intoler- 
ance, which  were  always  overcome  by  treating  the  nurse 
with  purgatives  and  by  restriction  of  her  diet.  It  became 
necessary  to  dismiss  the  wet-nurse.  A  carefully  adapted 
formula,  a  little  weaker  than  her  milk,  was  prepared.  The 
infant  refused  it  and  cried  persistently  whenever  the  bottle 
was  offered.  It  was  impossible  to  make  him  close  his  lips 
about  the  nipple.  On  one  occasion  the  nipple  was  held  in 
his  mouth  for  an  hour  and  a  half,  the  patient  crying  con- 
stantly. He  finally  took  2  or  3  ounces.  Within  five  or  six 
hours  he  had  diarrhea,  vomiting,  an  urticario-erythem- 
atous  rash  on  his  abdomen  and  legs,  and  a  temperature 
of  101°  F.  The  symptoms  speedily  subsided  after  the  ad- 
ministration of  castor  oil  and  the  withdrawal  of  the  milk. 
The  wet-nurse  had  to  be  recalled.  After  this  any  attempt 
(118) 


SUBSTITUTES   FOR  MILK  FORMULAS.  119 

to  feed  cows'  milk  was  resisted  and,  when  forced,  was 
always  followed  by  a  rash  and  gastrointestinal  symptoms. 
Weaning  had  to  be  finally  accomplished  by  the  direct  feed- 
ing of  solid  foods  and  broths  without  milk.  He  is  now  3 
years  of  age,  and  each  time  he  partakes  of  cows'  milk  or  of 
foods  cooked  with  milk  he  is  troubled  with  digestive  dis- 
orders and  an  eczematous  eruption. 

These  cases  are  probably  anaphylactic  in  character,  and 
represent  an  example  of  so>-called  allergia  to  cow-protein. 
Whenever  an  infant  vigorously  refuses  cows'  milk,  this  in 
itself  should  be  definitely  considered  before  pushing  the 
food.  In  Kerley's  case  the  first  symptoms  also  followed 
the  forcing  of  the  milk  upon  the  infant.  Laboratory 
investigations  may  later  disclose  a  method  whereby  this 
type  of  protein  intolerance  can  be  recognized  by  a  skin 
test  done  after  the  manner  of  the  von  Pirquet  reaction. 

SUBSTITUTES  FOR  MILK  FORMULAS. 

Whey. — Whey  is  made  by  coagulating  milk  with  ren- 
nin  or  essence  of  pepsin.  To  i  pint  of  sweet  or  skimmed 
milk  is  added  either  2  teaspoonfuls  of  liquid  rennet  or 
Fairchild's  essence  of  pepsin.  The  milk  is  then  placed  upon 
the  fire  and  gently  heated  to  blood  heat.  It  is  then  removed 
from  the  source  of  heat  and  permitted  to  clot.  The  clot 
is  now  broken  up  with  a  fork  or  a  spoon,  and  the  whole 
is  filtered  through  5  or  6  layers  of  narrow-mesh  cheese- 
cloth, without  pressure.  Whey,  when  correctly  made,  is 
almost  transparent  and  should  be  free  from  oil  globules  and 
flocculi  of  curd. 

When  it  is  desired  to  feed  a  child  upon  a  food  in  which 
casein  is  entirely  eliminated,  whey  feeding  may  be  etn- 
ployed.  It  is  easily  digested  and  forms  an  admirable 


120  ARTIFICIAL  FEEDING. 

vehicle  in  which  to  administer  stimulants.  It  is  an  excel- 
lent substitute  for  milk  in  the  management  of  some  of  the 
gastrointestinal  disorders  of  infancy.  It  may  be  given  plain 
or  diluted  with  milk,  barley-water,  or  cream  (see  below). 
Whey-and-Cream  Mixtures  (Split  Proteins). — In  the 
feeding  of  artificially  reared  children,  the  use  of  a  whey- 
and-cream  mixture  may  be  of  advantage.  Before  whey  is 
added  to  cream  or  milk  it  should  be  subjected  to  a  tempera- 
ture of  150°  F.  in  order  to  destroy  the  action  of  the  ren- 
nin  or  pepsin.  Otherwise  the  cream  will  curdle.  The  whey 
should  not  be  subjected  to1  a  temperature  higher  than  this, 
otherwise  the  lactalbumin  will  be  coagulated.  The  mix- 
tures of  whey  and  cream  may  be  of  service  in  instances 
wherein  milk  or  milk  formulas  are  not  tolerated  at  all. 
The  good  effects  are  shown  by  a  gain  in  weight  and  normal 
stools.  These  mixtures  are  only  to  be  regarded  as  substi- 
tutes, and  a  return  to  milk  should  be  gradually  made  as 
tolerance  is  indicated.  The  cream  is  added  in  gradually 
increasing  amounts,  starting  with  f3ss  to  f3j  to  each  bottle 
of  4  or  5  ounces  of  whey.  Where  it  is  desired  to  lessen 
the1  amount  of  calcium  casein  and  to  increase  the  whey- 
protein  (lactalbumin  and  lactoglobulin),  instead  of  whole 
milk  in  full  strength,  one  may  use  sweet  or  skimmed  milk 
diluted  with  varying  quantities  of  whey.  The  proteins 
of  whey  equal  about  i  per  cent.  Thus,  if  equal  parts  of 
whey  and  skimmed  milk  are  added  together,  the  resulting 
mixture  would  contain  about  0.75  per  cent,  of  whey-proteins 
and  about  2  per  cent,  of  calcium  casein.  These  mixtures 
are  also  of  use  where  plain  diluted  cows'  milk  is  not  toler- 
ated. For  practical  purposes  it  is  neither  necessary  nor 
useful  to  accurately  calculate  the  percentages  of  split  pro- 


SUBSTITUTES   FOR  MILK  FORMULAS.  121 

teins  being  fed.  The  guides  are  the  infant's  digestion  and 
its  weight. 

Wine  Whey. — Four  ounces  of  sherry  wine  are  added  to 
i  quart  of  milk  and  the  mixture  boiled.  Strain  through 
cheesecloth.  It  is  useful  as  a  stimulant  fed  in  small 
amounts,  plain  or  diluted  with  milk  or  cereal-water. 

Albumin-water. — Add  the  white  of  i  fresh  egg  to  a  pint 
of  water.  Shake  well.  Strain.  Salt  and  sugar  to  taste  if 
desired.  Feed  plain  or  dilute  with  cereal  water,  or  employ 
as  a  vehicle  for  fresh  beef-juice,  orange-juice,  or  brandy. 
When  all  milk  is  withdrawn,  albumin-water,  plain  or 
modified,  as  above,  serves  as  an  excellent  substitute  article 
of  diet,  in  the  treatment  of  diarrhea  cases  or  other  types  of 
indigestion. 

Sour  Milk  or  Acidified  Milk;  Lactic  Acid  Milk;  Butter- 
milk.—Milk  to  which  lactic  acid  bacilli  have  been  added, 
accidentally  or  intentionally,  undergoes  a  process  of  fer- 
mentation whereby  the  different  varieties  of  bacilli,  of  which 
the  Bulgarian  type  is  the  most  common,  change  the  lactose 
to  lactic  acid.  This  process  is  partial  or  complete  as  the 
time  of  fermentation  is  short  or  long.  Accidentally  soured 
milk  should  rarely  if  ever  be  employed,  as  there  is  great 
danger  of  pathologic  bacterial  infection  being  present,  as 
well  as  obscure  chemical  processes  which  may  cause  serious 
trouble.  Depending  upon  the  amount  of  fat  desired  in  the 
sour  milk,  whole  sweet  milk  or  skimmed  milk,  sometimes 
previously  sterilized,  is  employed.  Previous  sterilization 
is  usually  to  pro-long  the  souring  for  too  great  a  length 
of  time.  To  the  milk  is  added  i  or  2  of  the  many  varieties 
of  lactic-acid-bacilli  tablets  to  be  found  upon  the  market. 
These  are  previously  dissolved  in  a  little  milk  or  water.  Of 
these  the  Lactone  Tablets  of  Parke  Davis  &  Co.,  or  those 


122  ARTIFICIAL  FEEDING. 

prepared  by  Fairchild  Brothers  &  Foster,  or  the  Bulgarian 
Tablets  of  Hynson  &  Westcott,  have  given  satisfaction, 
although  all  of  them,  at  times,  may  be  found  to  be  inert. 
The  milk  is  kept  at  room  temperature  overnight,  after  the 
tablet  has  been  added.  By  morning,  coagulation  has  oc- 


Fig.  24. — Home  buttermilk  churner.     (Gimbel  Bros.,  Phila.,  Pa.) 

curred.  It  is  then  beaten  up,  and  is  ready  for  use.  If  whole 
milk  or  cream  has  been  used,  after  souring,  it  may  be  placed 
in  a  churner  (Fig.  24)  to  remove  the  fat  in  the  shape  of 
butter,  and  the  remainder,  or  the  buttermilk,  is  decanted. 
Whole  milk  soured  and  simply  beaten  up,  is  erroneously 
designated  as  buttermilk.  Soured  skimmed  milk  more 


SUBSTITUTES   FOR  MILK  FORMULAS.  123 

closely  approximates  buttermilk  which  contains  very  little 
fat.  The  souring  may  be  very  conveniently  brought  about 
by  simply  adding  to  a  quart  of  sweet  milk  a  teaspoonful  or 
two  of  sour  milk.  This  is  called  a  "starter,"  and  takes  the 
place  of  the  tablet.  Thus  each  day  a  little  of  the  soured 
milk  of  the  day  previous  may  be  used  for  this  purpose. 

The  composition  of  these  milks  varies  in  fat  content, 
depending  upon  whether  they  are  made  from  whole  sweet 
milk  or  skimmed  milk.  They  contain  approximately  the 
same  amount  of  protein  as  plain  whole  milk,  and  identical 
quantities  of  lactose  which  is  considerably  reduced  by  the 
fermentation.  The  composition  of  buttermilk  varies,  and 
depends  whether  it  be  made  by  simply  souring  skimmed 
milk  or  whole  milk;  or  whether  it  is  churned  from  sour  cream 
or  sour  whole  milk.  It  is  poor  in  sugar  and  contains  rela- 
tively more  protein  than  fat.  The  protein  exists  in  a  finely 
divided  state. 

AVERAGE  COMPOSITION. 

Protein 3.0  per  cent. 

Lactose    1.5  per  cent. 

Fat    2.5  per  cent. 

Salts    0.5  per  cent. 

Prepared  Buttermilk. — A  preparation  of  buttermilk 
much  used  at  the  Philadelphia  General  Hospital  (Blockley 
mixture)  follows :  Depending  upon  whether  the  living  lac- 
tic acid  organisms  shall  enter  the  infant's  gastrointestinal 
tract  or  not,  one  of  two  methods  may  be  employed : — 

i.  Three  and  three-fourths  teaspoonfuls  of  wheat-flour 
are  rubbed  into  a  smooth  paste  with  a  little  water,  and  suffi- 
cient water  added  to  make  a  quart;  15  24  teaspoonfuls  of 
cane-sugar  are  dissolved  in  this.  The  whole  is  boiled  for 
twenty  minutes  with  constant  stirring,  the  water  of 


124  ARTIFICIAL   FEEDING. 

evaporation  being  replaced.  Allow  it  to  cool.  Add  i  quart 
of  soured  whole  or  soured  skimmed  milk,  or  buttermilk. 

2.  After  mixing  as  above,  the  mixture  is  again  brought 
to  the  boiling  point.  The  flame  must  be  low  and,  as  soon 
as  heat  is  applied,  vigorous  stirring-  is  commenced  and  con- 
tinued until  the  boiling  point  is  reached  with  but  momentary 
interruptions ;  otherwise,  the  curd  will  unite  into  a  thick, 
tough,  solid  mass.  At  the  end  of  the  process  sterile  water 
is  added  to  make  the  entire  bulk  equal  2  quarts.  In  this 
preparation  the  lactic  acid  bacilli  are  destroyed. 

The  amount  of  cane-sugar  added  may  be  varied  as  the 
condition  of  the  infant's  digestion  indicates  tolerance  or 
otherwise.  It  may  be  often  advantageously  omitted  en- 
tirely, when  the  mixture  can  be  sweetened  with  saccharin 
gr.  j  to  the  quart.  Used  in  this  manner,  especially  if  sub- 
jected to  the  second  boiling,  it  may  form'  a  good  substitute 
for  eiweissmilch,  which  it  closely  resembles.  The  purpose 
of  the  addition  of  the  flour  is  to  take  the  place  of  the  defi- 
cient fat  and.  assist  in  the  formation  of  a  finely  divided  curd. 
The  additional  sugar  also  supplies  heat  and  energy  to  sup- 
plant that  of  the  sugar  lost  by  fermentation,  and  also'  of  the 
fat  removed  by  churning. 

Indications. — These  different  varieties  of  lactic  acid 
milk  are  useful  in  disturbances  of  digestion  where  diffi- 
culty is  experienced  in  taking  care  of  the  curd,  or  where 
a  decidedly  lessened  amount  of  sugar  is  desirable.  On 
account  of  the  fine  state  of  mechanical  division  in  which  it  is 
found,  the  curd  is  rendered  easily  digestible.  If  fed  raw, 
the  additional  effect  of  the  lactic  acid  bacilli  is  secured. 
This  may  be  of  considerable  assistance  in  tubercular 
enteritis.  In  one  case  the  acid-fast  bacilli  were  made  to 
disappear.  The  more  commonly  useful  mixture  is  the  one 


SUBSTITUTES    FOR   MILK   FORMULAS.  125 

to  which  flour  and  sugar  have  been  added.  It  finds  its 
special  sphere  in  intestinal  conditions  marked  by  protein 
and  fat  intolerance.  Green  stools,  curds,  diarrhea,  and 
mucus,  associated  with  loss  of  weight  and,  at  times,  tem- 
perature, often  speedily  disappear  after  the  use  of  this  food. 
If  they  persist,  before  the  mixture  is  discontinued  it  should 
be  tried  without  the  addition  of  cane-sugar.  In  either  in- 
stance the  cessation  of  symptoms  and  the  gain  in  weight, 
which  may  be  a  pound  or  more  the  first  week,  are  at  times 
only  short  of  marvelous.  Sugar  may  be  cautiously  added 
and  slowly  increased,  after  the  stools  become  normal. 
Buttermilk  milk  mixture  must  not,  however,  be  regarded  as 
a  permanent  food. 

A  time  comes  when  the  gain  in  weight  is  quite  small  or 
does  not  occur  at  all;  at  the  same  time  the  infant  seems  to 
take  a  great  dislike  for  the  mixture  which  previously  he 
had  relished.  A  change  must  therefore  be  made  to  other 
food.  This  is  done  promptly,  usually  after  omitting  one 
feeding  in  order  to  allow  the  stomach  to  become  completely 
empty.  Either  diluted  skim  milk  (preferable  at  first)  or 
diluted  whole  milk,  with  or  without  flour  ball  or  Benger's 
Food,  is  substituted.  Throughout  the  period  of  buttermilk 
feeding  the  infant  receives  from  i  to  2  drams  of  expressed 
beef -juice  three  times  a  day,  as  well  as  from  i  to  2  daily 
inunctions  of  codliver  or  olive  oil.  Two  great  advantages 
of  the  buttermilk  mixture  are  its  cheapness  and  the  ease  of 
its  preparation.  It  therefore  has  a  great  field  of  usefulness 
among  the  poor  and  among  the  ignorant. 

Buttermilk  Conserve. — This  comes  in  tin  cans  and  re- 
sembles closely  the  mixture  of  buttermilk,  wheat-flour,  and 
sugar.  It  is  thick  and  must  be  removed  from  the  can  as 
soon  as  the  latter  is  opened.  It  is  diluted  with  water.  It 


126  ARTIFICIAL  FEEDING. 

is  a  little  more  convenient  therefore,  especially  while  travel- 
ling, than  the  home-made  mixture.  Personal  experience 
with  it  has  been  limited.  The  analysis  provided  by  Biedert 
and  Selter  shows: — 

Proteins   9.6  per  cent. 

Fat  0.6  per  cent. 

Sugar  30.0  per  cent. 

Salts  2.0  per  cent. 

Lactic  acid 1.7  per  cent. 

Wheat-flour 4.5  per  cent. 

Where  cane-sugar  seems  to<  cause  disturbance,  use  may 
be  made  of  a  buttermilk  conserve  containing  Dextri-Maltose, 
marketed  by  Louis  Hoos,  of  Chicago. 

Eiweissmilch  (Albumin  Milk,  Finkelstein's  Milk,  Pro- 
tein Milk.) — The  following  method  of  preparing  eiweiss- 
milch  is  practised  by  Finkelstein  in  his  well-equipped  diet 
kitchen  in  the  Waisenhaus  u.  Kinderasyl  in  Berlin :  i  tea- 
spoonful  of  any  milk  coagulant,  as  rennin  or  pepsin,  is 
added  to  i  litre  of  whole  milk.  This  is  thoroughly  mixed 
and  the  vessel  containing  the  material  is  placed  in  a  water 
bath,  the  temperature  of  which  is!  about  no0  F.  This 
raises  the  milk  to  about  100°  F.  Within  a  short  period 
coagulation  occurs  and  the  entire  mixture  becomes  solid. 
The  mass  is  then  incised  by  a  complete  crucial  incision. 
This  facilitates  the  escape  of  the  whey.  The  coagulum  is 
now  placed  in  a  suspension  bag  (made  of  either  4  or  5 
layers  of  cheesecloth  or  of  a  porous  material  resembling  a 
thin,  unbleached  muslin)  for  a  period  of  four  hours.  This 
permits  all  the  whey  to  escape,  carrying  with  it  the  major 
portion  of  the  salts  and  the  sugar  of  milk.  The  tough  curd 
is  then  pushed  through  a  hair-mesh  sieve  in  order  to  com- 
pletely comminute  it.  This  process  is  accomplished  with  a 
wooden  spoon,  or  with  a  druggist's  pestle,  or  with  a  wooden 


SUBSTITUTES   FOR   MILK  FORMULAS.  127 

instrument  resembling  a  potato  masher.  It  is  repeated  four 
or  five  times,  adding  about  X  ntre  °f  water  to  facilitate 
the  passage  through  the  fine  sieve.  One-half  litre  of  good 
buttermilk  is  added  to  the  finely  divided  coagulum,  and  the 
entire  mixture  is  again  passed  through  the  sieve.  The 
bulk  of  the  product  should  equal  I  litre,  and,  should  it  not, 
the  deficiency  is  supplied  by  adding  sufficient  water.  The 
mixture  is  now  brought  to  the  boiling  point,  meanwhile 
stirring  thoroughly  and  constantly  from  the  moment  that 
heat  is  applied.  This  maneuver  is  crucial  in  its  effect  upon 
the  perfection  of  the  finished  product.  If  it  is  not  employed, 
the  finely  divided  curd  will  become  one  solid  mass.  This 
accident  seems  to  occur  with  great  frequency  in  America, 
while  in  Finkelstein's  kitchen  it  rarely  ever  happens. 
Whether  this  be  due  to  the  use  of  a  special  coagulant 
originally  (Labessenz,  made  by  Simon,  Berlin  c.  Spandauer- 
strasse  17),  or  whether  to  the  special  and  rather  complicated 
apparatus  which  is  employed  to  stir  the  mixture  while  it  is 
being  heated,  is  not  quite  clear,  although  I  incline  to  the 
view  that  the  latter  is  the  case.  In  questioning  the  Sister 
in  charge  of  the  kitchen,  on  this  point  I  could  receive  no 
definite  information,  chiefly,  I  believe,  because  she  never 
experienced  the  difficulty.  This  special  apparatus  has  a 
device  which  resembles  an  egg-beater,  and  for  this  reason 
I  have  employed  one  of  the  latter  with  which  to  do>  the 
stirring  while  the  mixture  is  being  heated.  The  stirring 
must  be  continued  during  the  process  of  cooling,  which  is 
accomplished  more  rapidly  by  permitting  cold  water  to  run 
over  the  containing  vessel.  Many  American  authors,,  in 
giving  their  directions  as  to  the  manufacture  of  eiweiss- 
milch,  omit  the  final  boiling.  This  is  incorrect  and  does  not 
represent  Finkelstein's  views.  In  my  own  experience  I  have 


128  ARTIFICIAL   FEEDING. 

been  able,  almost  without  exception,  to  prevent  this  coagula- 
tion en  masse  by  adding  a  dram  of  raw  wheat-flour  to  the 
mixture  before  applying  heat.  While  this  practice  too  is 
irregular,  it  does  not  seriously  interfere  with  the  correct 
composition  of  the  eiweissmilch,  and  certainly  does  not 
hamper  the  clinical  results. 

Composition. — Eiweissmilch  is  fat-poor,  sugar-poor, 
and  protein-rich.  An  average  analysis  follows: — 

Fat    2.5  per  cent. 

Protein 3.0  per  cent. 

Milk-sugar    .' 1.5  per  cent. 

Ash 0.5  per  cent. 

The  calcium  paracasein,  or  curd,  is  in  a  finely  divided  state. 
The  milk  is  sterile.  Eiweissmilch  contains  less  sugar  than 
buttermilk. 

The  difficulty  experienced  in  preparing  eiweissmilch  in 
the  home  has  caused  its  manufacture  to  be  undertaken  on  a 
large  scale,  in  Germany.  In  America  and  also  in  Germany 
it  may  be  found  upon  the  market  in  powdered  form;  90 
grams  of  this  preparation  are  added  to  1000  cubic  centim- 
eters of  previously  boiled  and  cooled  water,  and  thoroughly 
mixed. 

Larosan  is  also'  a  substitute  product.  It  is  eiweiss  cal- 
cium, or  a  combination  of  the  protein  of  milk  and  lime. 
About  2  per  cent,  is  added  to  l/2  litre  of  water.  To  this  is 
added  y2  litre  of  whole  milk  and  the  entire  mixture  is 
boiled.  It  is  employed  to  correct  dyspeptic  stools  before 
resorting  immediately  to  eiweissmilch.  Additional  carbo-- 
hydrate in  the  form  of  cane-sugar  or  of  Dextri-Maltose  may 
be  added  if  desired.  (See  Diarrhea,  Chapter  IX.) 

Uses. — Although  usually  employed  full  strength,  eiweiss- 
milch may  be  diluted.  On  account  of  its  deficiency  of 


PLATE  IX 


Stool  of  a  case  of  diarrhea  discolored  by  bismuth.  Notice 
absence  of  fecal  matter  and  the  excess  of  mucus.  Artificially 
fed  baby:  stool  commonly  seen  in  intoxication.  (See  text  for 
treatment  of  sugar  intolerance  and  diarrhea.) 


SUBSTITUTES   FOR   MILK   FORMULAS.  129 

sugar,  it  may  be  rejected  by  some  infants.  In  order  to 
overcome  this  I  grain  of  saccharin  may  be  added  to  a  quart. 
To  increase  its  caloric  value  the  addition  of  sugar  in  the 
form  of  Loeflund's  Maltose  or  Mead- Johnson's  Dextri- 
Maltose  is  usually  made.  At  first  2.y2  per  cent,  and  then 
5  pel"  cent,  is  added,  four  or  five  days  after  starting  the 
feeding,  or  when  the  bowels  become  normal. 

Eiweissmilch  undoubtedly  finds  its  greatest  field  of  use- 
fulness in  the  treatment  of  summer  diarrhea  and  next  in 
cases  of  infantile  dyspepsia,  wherein  difficulty  is  experienced 
in  the  proper  digestion  of  the  protein  or  fat,  or  both. 
It  is  by  no  means  to  be  regarded  as  anything  but  a  tem- 
porary food,  although  some  children  gain  slightly  on  it. 

Its  effect  on  the  diarrhea  and  character  of  the  stools  is 
almost  immediate.  From  8  to  10  or  more  movements  a  day 
the  number  is  speedily  reduced  and  their  appearance  be- 
comes whitish  or  brownish  yellow,  and  constipated  (calcium 
soap  stools,  caseate  of  lime).  This  change  is  so  constant 
that  it  cannot  be  regarded  as  accidental.  Maltose  is  not 
added  to  the  milk  until  the  stools  are  normal.  From, 
eiweissmilch  the  change  is  made  to  the  required  dilution  of 
whole  or  of  skimmed  milk  immediately,  as  with  buttermilk, 
but  one  feeding  being  omitted  to  allow  the  stomach  to  empty 
itself. 

Ramogen,  a  conserve,  marketed  in  cans,  represents 
a  condensed  form  of  Biedert's  creami-and-whey  mixture, 
the  basic  idea  of  which  is  to  seek  a  combination  of  protein 
and  fat  acceptable  to  the  infantile  digestive  apparatus.  The 
relative  proportions  of  protein,  fat,  and  sugar  in  Ramogen 
are  based  upon  the  principle  of  the  amount  of  food  neces- 
sary for  growth.  The  fat  is  rendered  easily  digestible  by  a 
process  of  emulsification.  The  proteins  are  not  predigested. 


130  ARTIFICIAL  FEEDING. 

The  conserve  is  obtained  by  condensation  at  a  low  tempera- 
ture. It  is  sterile.  Cane-sugar  is  added  as  a  preservative. 
The  reaction  of  Ramogen  is  slightly  alkaline.  Its  com- 
position represents: — 

Proteins   7-Q    per  cent. 

Fat    16.5    per  cent. 

Sugar  34-6S  per  cent. 

Salts    1.5    per  cent. 

This  substance  is  especially  useful  in  some  cases  of  delicate 
digestion  associated  with  marked  disturbance  of  the  nutri- 
tional balance.  Cases  of  decomposition  (marasmus)  which 
have  passed  the  gamut  of  patented  foods  and  do*  not  seem 
able  to  digest  cows'  milk  fo'rmulas,  however  manipulated, 
have  shown  a  remarkable  gain  in  weight  and  passed  on  to 
complete  recovery  when  placed  upon  this  food.  It  also*  does 
well  in  many  cases  of  summer  diarrhea  after  the  acute 
symptoms  have  subsided,  following  the  period  of  barley- 
water  or  weak-tea  feeding  before  milk  formulas  are  again 
resumed,  and  where  sugar  is  well  tolerated. 

Ramogen  is  employed  by  diluting  it  either  with  water 
(to  be  preferred)  or  with  milk.  The  following  dilutions 
are  suggested : — 


Age. 

Mixture. 

Calories 

Percentages  of 

Ram. 

Water. 

in  100  c.c. 

Proteins. 

Fat. 

Carbhd. 

First     3  weeks 

i 

13 

25 

•52 

1.23 

2-7 

3  to    6  weeks 

i 

11-12 

27-26 

•56-.S3 

1.36-1.3 

3-2.8 

6  to    9  weeks 

i 

IO 

30 

•63 

1.48 

3-1 

9  to  15  weeks 

i 

9 

33 

•7 

1.65 

346 

15  to  18  weeks 

i 

8 

35 

•77 

1.81 

3-8 

18  to  21  weeks 

i 

754 

38 

.81 

1-93 

4.0 

21  to  24  weeks 

i 

7 

4i 

.87 

2.06 

4-3 

24  to  27  weeks 

i 

&/2 

43 

•93 

2.19 

4-7 

27  to  33  weeks 

i 

6 

45 

.98 

2.31 

4.8 

33  to  49  weeks 

i 

51A 

50 

1.07 

2-54 

5-3 

39  to  44  weeks 

i 

5 

54 

MS 

2.72 

5-7 

SUBSTITUTES    FOR   MILK   FORMULAS.  131 


Age. 

Mixture. 

Calories           Percentages 

of 

Ram. 

Water. 

Milk,     in  100  c.c.  Proteins.  Fat. 

Carbhd. 

4 

to 

6 

weeks 

I 

l2l/2 

2 

30            .92 

1-39 

2-5 

6 

to 

9 

weeks 

I 

12 

3 

33 

•  17 

1-54 

2.8 

9 

to 

IS 

weeks 

I 

u'A 

zlA 

35 

•29 

1.64 

2.88 

15 

to 

18 

weeks 

I 

II 

4 

37 

.42 

1-74 

3-0 

18 

to 

21 

weeks 

I 

lOl/2 

4/2 

39 

•54 

1.83 

3.12 

21 

to 

24 

weeks 

I 

10 

5 

4i 

.66 

1.92 

3-24 

24 

to 

27 

weeks 

I 

9/ 

SY* 

43            1.78 

2.01 

3.36 

27 

to 

30 

weeks 

I 

9 

6 

45            1-92 

2.1  1 

3-5 

30 

to 

33 

weeks 

I 

sy2 

654 

47            2.0 

2.19 

3-6 

33 

to 

36 

weeks 

I 

8 

7 

49            2.18 

2.24 

3.76 

33 

to 

30 

weeks 

I 

7/2 

7# 

5i            2.3 

2.4 

3-9 

Somatose  Milk. —  This  contains: — 

Proteins    8.8  per  cent. 

Fat  . . : 16.5  per  cent. 

Carbohydrates  34.6  per  cent. 

Salts   1.5  per  cent. 

It  is  practically  Ramogen  containing  lactosomatose,  which 
is  an  albumose  of  casein  and  contains  5  per  cent,  tannin  in 
firm  chemical  combination.  Its  purpose  is  supposed  to  take 
the  place  of  the  soluble  lactalbumin  in  mother's  milk,  which 
plays  an  important  factor  in  the  easy  digestibility  of  the 
curd.  It  is  very  readily  assimilable. 

Indications. — It  is  useful  in  all  cases  of  weak  digestion, 
in  acute,  subacute,  and  chronic  inflammation  of  the  intes- 
tinal tract,  and  in  wasting  diseases,  as  essential  marasmus, 
scurvy,  and  rickets.  It  is  employed  in  the  same  dilutions  as 
Ramogen. 

Condensed  Milk. — Milk  evaporated  in  vacuo,  after 
sterilization,  constitutes  condensed  milk.  It  may  be  sweet- 
ened or  unsweetened,  fresh  or  sold  in  cans.  The  last  is  the 
product  commonly  used.  It  contains  a  large  amount  of 
carbohydrate,  mainly  in  the  shape  of  cane-sugar,  which  is 
added  as  a  preservative.  When  the  can  is  opened  the  con- 


132  ARTIFICIAL  FEEDING. 

tents  should  be  poured  into  a  china  or  glass  pitcher.  It  is 
kept  covered  on  ice,  and  should  not  be  used  after  the 
second  day.  Its  composition,  according  to  the  manufac- 
turer, is  as  follows:— 

pat    9.61  per  cent. 

Protein    8.01  per  cent. 

Carbohydrate  (42.91  per  cent,  cane-sugar, 

12.03  per  cent,  lactose)    54-94  Per  cent. 

Salts 1.78  per  cent. 

Water    25.66  per  cent. 

100.0    per  cent. 

Condensed  milk  is  rich  in  sugar  and  poor  in  fat,  protein, 
and  mineral  salts.  It  has  been  a  very  much  unjustly  con- 
demned food  and,  at  the  same  time,  a  very  much  overused 
one.  Infants  fed.  exclusively  on,  condensed  milk  grow  fat, 
but  have  poor  resisting  powers,  readily  succumb  to*  the 
acute  infectious  diseases  and  pulmonary  trouble,  and  fre- 
quently develop  rickets  and,  less  often,  scurvy.  They  are 
often  anemic.  Nevertheless  condensed  milk,  properly 
diluted  to  the  digestive  capacity  (about  I  part  in  12  or  16 
of  water  at  the  outset,  increasing  the  strength  up  to  about 
i  in  6),  is  a  valuable  adjunct  to  our  feeding  armamen- 
tarium. It  is  best  given  diluted  with  a  cereal-water.  Where 
protein  or  fat  intolerance  exists,  this  food  is  often  valuable. 
Especially  has  it  been  found  useful  in  some  cases  of  summer 
diarrhea  as  a  go-between,  as  it  were,  between  the  starvation 
period  and  the  time  when  a  return  is  made  to  fresh  milk 
formulas.  Condensed  milk  should  only  be  employed  in 
those  cases  of  summer  diarrhea  where  it  can  be  proven  that 
the  condition  is  not>  dependent  upon  sugar  intolerance. 
After  the  acute  symptoms  have  subsided  a  weak  dilution  of 
condensed  milk  is  made  with  barley-water.  This  is  grad- 
ually strengthened,  and  one  bottle  of  the  condensed-milk 


CURD   MODIFIERS.  133 

feeding  is  daily  or  bidaily  replaced  by  a  weak  freshr-milk 
formula,  until  all  are  replaced.  The  fresh-milk  mixtures 
are  then  slowly  strengthened.  Condensed  milk  is  cheap. 
It  therefore  must  often  be  considered  when  feeding  the 
poor,  especially  in  rural  or  semirural  districts,  and  also  in 
summer,  as  it  is  practically  sterile  and  requires  only  the 
addition  of  a  sterile  diluent.  When  travelling  for  a  long 
distance,  it,  alone,  may  be  depended  upon.  When  continued 
over  any  length  of  time,  it  must  always  be  supplemented  by 
the  feeding  of  fresh  fruit-  or  vegetable-  and  beef-  juice. 

Soya  Bean.— This  has  been  much  advocated  by  Ruhrah. 
The  bean  is  made  into  a  flour  by  the  Cereo  Company  of 
Tappan,  N.  Y.,  and  contains  44  per  cent,  protein,  20  per 
cent,  fat,  10  per  cent,  cane-sugar,  and  a  trace  of  starch. 
In  infancy  it  has  been  recommended  as  a  gruel:  4  to  8 
level  tablespoonfuls  and  a  pinch  of  salt  are  added  to  i 
quart  of  water.  Boil  fifteen  minutes.  Strain.  Add  water 
to  a  quart.  Cool.  It  may  be  used  in  this  manner  or  added 
to  milk.  In  order  to  prevent  the  gruel  from  settling,  i  to  2 
teaspoonfuls  of  barley-water  may  be  added.  This  adds  0.6 
per  cent,  to  1.2  per  cent,  of  starch. 

CURD  MODIFIERS. 

The  following  substances,  useful  as  additions  to  or  sub- 
stitutes for  cows'  milk,  merit  special  mention  as  mechanical 
modifiers  of  the  curd  of  cows'  milk: — 

Flour  Ball  (Plain). —  One  pound  of  clean  wheat-flour 
is  tied  in  the  shape  of  a  ball  in  a  bag  made  of  unbleached 
muslin  or  balbriggan.  The  foot  of  a  new,  white  stocking, 
size  10,  will  answer.  It  is  placed  in  water  and  boiled  con- 
tinuously for  eight  hours.  At  the  end  of  this  time  it  is 
removed  from  the  bag  and  placed  on  a  plate  in  an  oven  and 


134  ARTIFICIAL   FEEDING. 

slowly  but  completely  dried  out.  It  will  appear  with  an 
outer  skin,  as  shown  in  Fig.  25.  It  is  now  cracked,  opened, 
and  the  inside  is  grated  or  pulverized  and  sifted.  The  pul- 
verized flour  ball  is  added  to  each  bottle  just  before  feeding, 
in  the  amount  of  from  ^  to  I  teaspoonful,  or  it  may  be 
used  as  detailed  in  Chapter  II,  page  108. 

Flour  Ball  (Dextrinized  or  Browned). —  This  is  made  as 
just  described,  except  that  after  breaking  open  the  ball  is 
baked  to  a  "bread  brown"  and  this  portion  is  grated  and 


Fig.  25. — Flour  ball.    One  is  cracked  open  into  three  pieces.    The  inside 
(£)  is  pulverized  and  sifted.    The  hard  shell  (A)  is  discarded. 

sifted.  This  baking  process  is  repeated  as  often  as  neces- 
sary. Flour  ball  will  keep  indefinitely,  provided  it  is  kept 
perfectly  dry  and  in  an  air-tight  container.  This  is  to  pre- 
vent the  growth  of  mold. 

Uses. — This,  an  old-fashioned,  time-honored  "grand- 
mother's remedy,"  has,  unfortunately,  been  almost  for- 
gotten and  passed  into  disuse.  It  is  an  excellent  agent 
to  add  to  the  formula  where  the  infant  cannot  digest  the 
curd  of  the  milk.  It  is  especially  healing  and  soothing  when 
this  condition  is  associated  with  diarrhea.  When  constipa- 
tion supervenes,  the  amount  of  flour  ball  should  be  grad- 
ually lessened  and  finally  omitted.  Browned  or  dextrinized 


CURD  ^MODIFIERS.  135 

flour  ball  should  be  used  in  those  cases  where  the  plain 
flour  ball  produces  too  much  gas,  as  it  may  in  infants  wiho 
cannot  digest  starch  very  well.  In  addition,  in  these  in- 
stances, when  the  simple  browning  is  insufficient,  i  or  2 
grains  of  Fairchild's  extract  of  pancreatin  may  be  added  to 
each  bottle. 

Benger's  Food. — Though  a  proprietary,  as  a  curd  modi- 
fier this  food  may  justly  find  a  permanent  place  in  the 
dietetics  of  infancy.  It  consists  simply  of  extract 'of  pan- 
creatin and  of  pulverized  flour  ball,  and  may  be  conveniently 
used  as  a  substitute5  for  it,  as  the  long  time  required  for  the 
preparation  of  the  latter  is  thus  omitted.  This  food  is  used 
in  the  proportion  of  5  per  cent,  of  the  total  formula  or  less, 
usually  less  (2.^/2  per  cent.).  The  ingredients  of  the  for- 
mula, with  the  exception  of  the  Benger's  Food,  are  mixed 
in  the  usual  manner.  A  small  quantity  of  the  mixture, 
about  an  ounce  or  two,  is  rubbed  into  a  smooth  paste  with 
the  Benger's  Food.  The  remainder  of  the  formula  is 
brought  to  the  boiling  point  in  a  double  boiler.1  This  is 
then  poured  over  the  paste.  Mix  well;  allow  to  stand 
fifteen  minutes  without  fire,  but  covered.  Heat  quickly  a 
second  time  to  the  boiling  point  in  a  single  boiler  placed 
over  a  low  flame.  Stir  the  mixture  constantly  to  prevent 
burning.  Cool.  Bottle.  Ice. 

The  effect  upon  green  stools  is  almost  immediate,  chang- 
ing them  to  a  smooth  yellow,  with  a  normal  or  slightly  acid 
reaction.  The  amount  of  Benger's  Food  is  gradually  re- 
duced and  finally  omitted.  The  only  objection  toi  the  use 
of  this  preparation  is  that  the  milk  must  be  boiled.  In  sum- 


1  It  must  be  remembered  that  substances  do  not  actually  boil  in  a 
double  boiler.  They  simply  steam  and  bubbles  are  seen  about  the 
edges ;  or  the  temperature  may  be  taken  with  a  thermometer. 


136  ARTIFICIAL   FEEDING. 

mer  this  is  an  advantage.  If  the  necessity  for  its  prolonged 
use  exists,  fruit-  and  meat-  juices  must  be  fed  to  the  infant. 
Imperial  Granum. — From  I  to  2  tablespoonfuls  of  Im- 
perial Granum  are  added  to  I  pint  of  milk  and  boiled  one- 
half  hour.  At  the  end  of  this  time  the  addition  of  a  suffi- 
cient quantity  of  water  is  made  to  bring  the  total  volume 
up  to  a  pint.  As  a  cereal-water  Imperial  Granum  is  a  use- 
ful curd  modifier,  and  adds  materially  to  the  nutrition  of 
the  formula  on  account  of  the  extra  starch,  which  most 
infants  are  able  to  digest  at  a  very  early  age  (Kerley). 
This  preparation  must  also  be  reinforced  by  the  feeding  of 
meat-,  vegetable-,  and  fruit-  juices. 

SUBSTITUTES  FOR  MILK-SUGAR. 

For  reasons  previously  stated  the  milk-sugar  of  com- 
merce frequently  forms  a  poor  substance  with  which  to*  pro- 
vide extra  carbohydrate.  For  this  purpose  other  sugars 
have  been  employed. 

Cane-sugar  (Saccharose)  in  many  instances  is  an  excel- 
lent substitute.  Experience  with  it  has  verified  all  that  is 
claimed  for  it  by  Jacobi.  One  ounce  equals  about  120 
calories. 

Mead's  Dextri-Maltose  and  Loeflund's  Food  Maltose. — 
Malt-sugar,  or  maltose,  is  more  rapidly  absorbed  than 
either  lactose  or  saccharose.  The  degree  of  assimilability 
of  these  three  sugars  is  indicated  as  follows:— 

Maltose 7.7  grams  +  per  kilogram  (Ruess). 

Lactose  3.1  to  3.6  grams  per  kilogram  (Gross). 

Saccharose About  the  same  as  lactose  (Ruess). 

The  power  to  assimilate  maltose  is  therefore  double  that  of 
the  other  two.  It  has  been  further  shown  that  larger 
amounts  of  maltose  can  be  taken  by  the  infant  than  either 


SUBSTITUTES  FOR  MILK-SUGAR.  137 

of  lactose  or  saccharose,  without  sugar  appearing  in  the 
urine.  This  is  probably  due  to  the  fact  that  maltose,  ab- 
sorbed as  such  into  the  body,  is  acted  upon  by  a  special 
ferment  found  in  the  muscles,  blood,  and  other  tissues. 
Maltose  causes  a  more  rapid  gain  in  weight.  Its  combina- 
tion with  dextrin  increases  this  power.  It  does  not  readily 
ferment  in  the  intestinal  tract.  For  dietetic  purposes,  how- 
ever, pure  maltose  is  inaccessible  on  account  of  its  expense. 
It  therefore  appears  on  the  market  in  combination  with 
dextrin  in  the  shape  of  Mead- Johnson's  Dextri-Maltose  and 
as  Loeflund's  Food  Maltose.  These  resemble  each  other 
closely;  the  latter  being  imported,  is  therefore  more  ex- 
pensive. They  are  each  added  to  the  formula  in  any  extra 
percentage  desired,  from  I  to  5  per  cent. ;  i  ounce  to  a  20 
ounce  mixture  equals  5  per  cent,  extra  carbohydrate. 
When  maltose  is  employed  the  stool  is  often  characteris- 
tically brown  or  brownish  yellow.  One  ounce  of  either  of 
these  preparations  approximates  120  calories. 

Composition  of  Dextri-Maltose. — This  practically  con- 
sists of  starch  converted  by  malt  diastase,  the  percentage  of 
maltose  and  dextrin  being  respectively  regulated  by  the 
temperature  at  which  the  process  is  stopped  and  the  length 
of  time  of  exposure  to  this  temperature.  It  contains 
neither  cellulose,  protein,  nor  fat : — 

Maltose   51.0  per  cent. 

Dextrin 42.7  per  cent. 

Salts   2.0  per  cent. 

Moisture 4.3  per  cent. 

Composition  of  Loeflund's  Food  Maltose. — Loeflund's 
Food  Maltose  contains,  approximately: — 

Dextrin    60.0  per  cent. 

Maltose    40.0  per  cent. 

Salts   0.3  per  cent. 


138  ARTIFICIAL  FEEDING. 

Soxhlet's  Nahrzucker. — This  preparation  is  marketed 
by  the  Arcady  Farms  of  Lake  Forrest,  111.  It  is  added  as 
extra  carbohydrate  in  the  amounts  of  i  to  5  per  cent,  of  the 
milk  formula.  It  is  called  nutrient  sugar,  and  was  elab- 
orated by  Prof.  Dr.  Soxhlet.  It  is  dissolved  in  boiling 
water.  The  milk  and  other  ingredients  of  the  formula  are 
added  and  the  whole  sterilized.  Its  composition  is  similar 
to  Dextri-Maltose  and  Food  Maltose. 

FEEDING  AFTER  THE  FIRST  YEAR. 

At  12  months  an  infant  should  be  receiving  whole,  un- 
diluted, cows'  milk.  At  this  time  additions  should  be  made 
to  the  dietary  in  the  shape  of  cereals,  and  other  foods  to  be 
detailed.  This  statement  bears  modification  in  so  far  as 
some  .infants  are  able  to  digest  whole  milk  at  an  earlier 
age,  and,  at  the  same  time,  to  receive  foods  that  require 
chewing.  Others,  again,  may  not  be  able  to  take  care  of 
strong  food  at  this  time.  It  is  clearly  a  problem  of  the 
individual.  Many  children  beyond  a  year  of  age  are  seen 
whose  nutrition  has  suffered  for  the  want  of  strong  food, 
and  who  are  weak  and  undernourished.  In  these  cases  a 
change  in  diet  to  solids  is  productive  of  marvelous  results. 
On  the  other  hand,  it  must  not  be  forgotten  that  malnutri- 
tion results  as  well  from  overfeeding  as  feeding  an  infant 
things  which  it  cannot  digest.  How  are  we  to  judge,  and 
what  are  the  guides  to  indicate  that  the  gastrointestinal 
tract  is  ready  for  the  digestion  of  food  that  requires  com- 
minution? Aside  from  the  condition  of  the  general  health 
and  of  the  digestion,  the  one  single  thing  that  would  indi- 
cate digestive  strength  is  the  presence  of  several  teeth. 
This  is  a  safe  indication  to  commence  the  feeding  of  solids 


FEEDING   AFTER   FIRST   YEAR.  139 

and  semisolids  irrespective  of  the  age,  provided  the  infant 
is  not  suffering  from  indigestion. 

The  use  of  the  bottle  should  not  be  permitted  beyond 
12  months  in  most  instances,  and  promptly  at  this  time  the 
infant  may  be  taught  to  take  its  milk  from  a  cup.  Some 
babies  take  and  relish  other  food,  especially  thin  cereals  and 
rusk  or  zweiback,  as  early  as  6  months,  but  as  a  general 
proposition  the  end  of  12  months  is  the  best  time  to 
commence  extra  feeding.  A  practical  point  of  importance 
is  the  statement  frequently  volunteered  by  the  mother,  that 
her  baby  will  not  take  this  or  that  food.  The  acceptance  of 
foods  other  than  the  bottle  is  a  matter  of  education,  and  the 
baby  must  get  used  to  the  new  substances.  Thus,  an  infant 
may  refuse  an  egg.  It  should  not  be  forced,  but  one  should 
be  offered  to  it  again  in  a  few  weeks  or  a  month.  The 
additions  to  the  food  should  be  gradual  and  should  consist 
primarily  of  well-cooked  cereals,  as  oatmeal,  cream  of 
wheat,  and  cornmeal.  These  should  be  cooked  at  least  two 
hours,  with  or  without  milk,  and  served  either  with  milk 
and  sugar  or  with  butter  or  meat-juice.  Rice  is  a  useful 
cereal  at  this  time,  but  must  be  cooked  at  least  three  hours. 
Mashed  baked  potato  (page  147),  with  milk  and  butter  or 
beef -juice,  is  of  value.  Bread  and  butter  may  also  be 
allowed.  For  desserts,  junket  or  rice-,  sago-,  or  other  pud- 
ding, or  mashed  baked  apple,  or  the  inside  of  prunes,  may  be 
used.  At  this  age  infants  should  receive  not  more  than  five, 
and  better  but  four,  meals  a  day,  so  arranged  as  to  give 
plenty  of  rest  for  the  stomach,  and  that  the  heaviest  meal 
should  be  given  in  the  middle  of  the  day  and  the  lightest 
at  night.  The  schedule  appended  has  given  uniform 
satisfaction : — 


140  ARTIFICIAL   FEEDING. 

DIET  No.  i. 
Diet  for  Age 

Date    

Breakfast  (6.30  to  7  A.M.).— (i)  Glass  of  milk  and  stale  bread 
broken  in  it.  (2)  Cereal,  as  oatmeal,  arrowroot,  rice,  grits,  cooked  at 
least  two  hours  (rice,  three  hours),  and  covered  with  milk.  If  desired, 
can  be  sweetened  to  taste.  (3)  Soft-boiled  egg  and  bread  and  glass  of 
milk. 

Second  Meal  (10  A.M.). — Milk. 

Third  Meal  (2  P.M.).— (i)  Beef-blood,  beef-tea,  or  fat-free  gravy 
containing  stale  bread  broken  in  it,  and  a  glass  of  milk.  (2)  Rice  and 
grits  cooked  three  hours  or  mashed  baked  patato  with  beef-tea  or  beef- 
blood  or  gravy.  (3)  Soft-boiled  egg,  buttered  stale  bread,  and  glass  of 
milk.  Rice-,  sago-,  or  other  pudding,  or  junket,  can  be  given  for 
dessert;  mashed  baked  apple. 

Fourth  Meal  (5  P.M.  to  6  P.M.). — Glass  of  milk  or  milk 'and  crackers. 

Fifth  Meal  (9  to  10  P.M.). — Glass  of  milk. 
This  diet  should  not  be  used  beyond  the  age  of  18  months. 

The  fifth  meal  may  preferably  be  omitted  and  the  time  of 
feeding  indicated  may  be  adjusted  to  fit  the  routine  of  the 
household.  If  an  infant  has  been  kept  on  the  breast  up  to 
the  age  of  12  months  or  longer,  the  change  to  this  diet  may 
be  made  at  once,  except  that,  where  it  calls  for  milk,  diluted 
milk  may  be  given  at  first.  If  an  egg  be  given  for  breakfast, 
it  should  not  be  given  at  the  midday  meal,  one  a  day  being 
ample. 

At  the  age  of  18  months,  further  additions  may  be  made, 
especially  at  the  midday  meal.  Soups  made  from  mutton, 
fish,  or  chicken,  either  plain  or  containing  a  cereal  or  vege- 
table, are  valuable.  The  most  important  addition  is  meat 
in  the  shape  of  finely  cut,  rare,  broiled  steak;  lamb-chop, 
roast  beef,  boiled  fish,  or  white  meat  of  chicken.  Desserts 
may  include  custard  and  bread-pudding.  Only  three  prin- 


FEEDING   AFTER    SECOND   YEAR.  141 

cipal  meals  a  day  are  given,  with  a  very  light  lunch  between, 
at  10  A.M.  and  at  4  P.M.  :— 

DIET  No.  2. 
Diet  for Age 


Date 


Breakfast  (7  to  8  A.M.). — (i)  A  slice  of  bread  and  butter  or  soda 
or  graham  cracker,  or  shredded-wheat  biscuit  with  a  glass  of  milk.  (2) 
Soft-boiled  egg,  glass  of  milk,  bread  and  butter.  (3)  Oatmeal,  arrow- 
root, wheat-grits,  hominy,  cream  of  wheat  (farina),  cooked  at  least  two 
hours  with  milk;  glass  of  milk. 

Lunch    (10   A.M.) — Glass   of   milk   with    stale   bread,  zweiback  or 
cracker,  buttered  if  preferred. 

Dinner  (2  P.M.). —  (i)  Rice  boiled  three  hours,  with  meat-gravy  or 
milk,  or  mashed  baked  potato  moistened  with  butter  or  beef-juice; 
glass  of  milk.  (2)  Clear  vegetable  soup  or  soup  made  from  mutton, 
lamb,  fish,  or  chicken,  clear  or  containing  rice,  celery,  sago,  farina,  or 
stale  bread  or  crackers  broken  in  it;  bread  and  butter,  and  rice-,  sago-, 
or  bread-  pudding;  custard,  junket,  apple-sauce,  or  stewed  prunes 
(pulp),  as  dessert.  (3)  Soup,  small  piece  of  finely  cut  white  meat  of 
chicken,  broiled  lamb-chop,  tender  steak,  roast  beef,  or  boiled  fish,  bread 
and  butter,  and  dessert. 

Afternoon  Meal  (4  P.M.). — One  to  three  lady  fingers,  or  piece 
zweiback. 

Evening  Meal  (6  P.M.). — Bread  (plain  or  buttered)  and  milk. 
This  diet  is  not  to  be  used  beyond  2  years. 

FEEDING  AFTER  THE  SECOND  YEAR. 

The  diet  now  commences  to  assume  more  of  the  char- 
acteristics of  that  of  the  adult,  in  that  a  greater  variety  of 
food  is  allowed.  The  afternoon  luncheon  is  often  omitted. 
Occasionally  a  little  pure  ice-cream  and  a  lady  finger  are 
allowed.  Between  7  and  8  A.M.  breakfast  is  served  and  con- 
sists of  orange- juice,  scraped  raw  apple,  raw  ripe  or  stewed 
peaches,  apple-sauce,  California  grapes  freed  of  skin  and 
seed,  baked  apple  or  stewed  prunes,  cereal — as  oatmeal, 


142  ARTIFICIAL  FEEDING. 

hominy,  wheaten  grits,  cream  of  wheat,  or  other  porridge; 
a  small  portion  of  finely  cut  beefsteak  (broiled)  or  lamb- 
chop,  and  bread  and  butter  and  a  glass  of  water.  If  meat 
be  omitted,  and  it  should  be  if  fed  at  noon,  an  egg  and  a 
glass  of  milk  may  be  substituted  in  the  morning.  At  10 
A.M.  the  child  may  receive  its  bath,  to  be  followed  by  a 
small  glass  of  milk  and  a  cracker,  or  a  small  cup  of  broth. 
Its  morning  nap  follows.  Dinner  is  served  at  1.30  or  2 
P.M.,  and  consists  of  soup,  a  meat,  two  vegetables,  bread 
and  butter,  dessert,  and  a  glass  of  moderately  cold,  pure 
water.  The  varieties  for  selection  are  noted  below.  At 
6  P.M.  a  supper  consisting  of  bread  and  butter  and  milk,  or 
bread  and  butter  and  apple-sauce  and  water,  is  given: — 

DIET  No.  3. 

Diet  for Age 

Date   . 


Breakfast  (7  to  8  A.M.). —  (i)  Orange-juice,  scraped  raw  ripe 
apple,  raw  ripe  or  stewed  peaches,  apple-sauce,  grapes  freed  of  skin  and 
seeds,  baked  apple  or  stewed  prunes,  oatmeal,  hominy  grits,  wheaten 
grits,  cream  of  wheat,  or  other  cereal  porridge,  well  cooked  and  served 
with  plenty  of  milk  and  sugar  to  taste ;  small  portion  of  finely  cut 
broiled  beefsteak  or  lamb-chop,  with  bread  and  butter.  (2)  Cereal  and 
fruit  as  above,  with  soft-boiled  or  poached  egg,  with  bread  and  butter 
and  a  glass  of  milk. 

Second  Meal  (10.30  A.M.).— (i)  Glass  of  milk,  with  bread  and  but- 
ter, or  soda  cracker.  (2)  Bread  and  milk  or  graham  crackers  and  milk. 
Chicken-  or  mutton-  broth,  with  bread  or  crackers. 

Dinner  (1.30  P.M.): — Clear  soup  made  from  beef,  chicken,  lamb  or 
fish,  or  soups  containing  well-cooked  rice,  barley,  farina,  celery,  or 
noodles,  or  oyster-  or  clam-  broth ;  roasted  or  broiled  or  stewe'd  chicken, 
turkey,  squab,  beef,  lamb,  fresh  fish  cut  fine ;  mashed  baked  potato  with 
butter  or  beef-blood  on  it;  stewed  celery;  asparagus  tips;  spinach 
(German  style)  ;  stewed  noodles  with  milk  dressing ;  stewed  onions  ; 
skinned  and  mashed  peas  and  lima  beans ;  creamed  squash ;  bread  and 
butter.  As  dessert,  rice-,  sago-,  tapioca-,  farina-,  or  plain  bread-  pud- 


DIFFICULT    FEEDING   AFTER   FIRST    YEAR.          143 

ding;  junket,  egg-custard,  or  cornstarch,  or  any  of  the  fruits  mentioned 
above.  (Selection  for  dinner  should  consist  of  a  soup,  one  meat,  not 
more  than  two  vegetables,  bread  and  butter,  and  dessert.) 

Supper  (6  P.M.). — Bread  and  butter  and  milk,  or  crackers  and  milk, 
Diet  not  to  be  used  for  child  under  2  years. 

If  absolute  regularity  is  practised  at  this  time  and  no 
departure  is  made  from  the  foods  contained  in  the  list 
appended,  there  will  be  no  digestive  derangements.  Over- 
feeding or  yielding  to  the  importunities  of  the  child  will 
only  bring  disaster  to  it  and  sorrow  to  the  household.  Tea, 
coffee,  pastries,  and  an  undue  amount  of  sweets,  a  piece 
of  chocolate  being  allowed  each  day,  fresh  bread,  beer, 
alcohol  in  all  forms,  made  dishes,  smoked  or  pickled  foods, 
cheese,  bananas,  an  excessive  amount  of  cakes  and  ice- 
cream should  find  no  place  in  the  child's  dietary,  even  up  to 
the  age  of  5  or  6  years.  It  is  just  as  easy  to  train  a  child 
to  eat  and  to  relish  the  correct  foods  as  it  is  toi  allow  it  to 
eat  indigestibles.  The  gain  to  its  digestion  and  nutrition  is 
increased  many  fold. 

DIFFICULT  FEEDING  CASES  AFTER  THE 
FIRST  YEAR. 

In  those  children  who'  cannot  take  whole  milk,  Diet 
No.  i  may  be  given  with  the  breast  or  with  diluted  milk,  or 
with  no  milk  at  all.  These  cases  often  follow  an  attack  of 
summer  diarrhea  late  during  the  first  year,  or  during  the 
first  half  of  the  second  year.  A  return  to  milk  means  a 
renewal  of  symptoms,  and  main  reliance  must  be  placed 
upon  mutton-  or  beef-  broth,  cereals — as  rice  and  farina, 
and  stale  bread,  and  eggs.  A  diet  of  this  kind  will  often 
cause  the  stools  to  become  normal  without  the  use  of  medi- 
cation. The  return  to  milk  must  be  made  with  the  utmost 
caution,  using  it  boiled  at  first  and  well  diluted. 


144  ARTIFICIAL   FEEDING. 

Again,  cases  of  delicate  digestion  occur,  in  which  it  is 
impossible  to  place  one's  finger  exactly  on  the  cause.  All 
that  can  be  said  is  that  the  children  are  delicate.  Here 
individual  experience  and  experience  with  the  individual 
child,  alone  can  be  our  guide.  The  dietary  must  be  carefully 
scrutinized,  and  each  article  that  seems  to  disagree  must  be 
eliminated.  The  stools  must  be  carefully  studied  in  order 
to  learn  what  substances  pass  undigested.  As  a  rule, 
highly  seasoned  or  overfatty  foods  cause  disturbance.  In 
no  instance  should  the  evening  meal  be  large,  and  great  care 
to  prevent  overfeeding  should  at  all  times  be  taken,  the 
preferable  idea  being  to  give  several  small  meals.  Where 
vomiting  occurs  as  a  frequent  symptom,  proteins  are  to  be 
avoided,  as  they  may  be  responsible  for  an  increased 
acidosis,  as  shown  by  acetonuria,  and  the  acid  fruits  and 
carbohydrates  are  to  be  especially  pushed.  Where  night- 
terrors  occur,  with  febrile  attacks  and  indicanuria,  reduce 
the  proteins  and  sugars  and  increase  the  supply  of  water. 
During  an  attack  of  fever  all  food  had  better  be  withdrawn, 
or  at  best  the  diet  reduced  to  simple  liquids  (Chapter  XIII). 

FOOD  RECIPES. 

Beef-tea  No.  i. — To  i  pound  of  lean  chopped  beef,  free 
of  fat,  add  i  quart  of  water.  Boil  one  hour,  renewing  the 
water  from  time  to  time.  Strain.  Cool.  Remove  fat. 
Salt  to  taste.  Warm  before  feeding.  Fresh  daily. 

Beef-tea  No.  2. — To  i  pound  of  lean  chopped  beef  add 
i  quart  of  boiling  water.  "  Keep  warm  one-half  hour. 
Strain.  Place  on  ice.  Remove  fat  Salt  to  taste.  Warm 
before  feeding.  Fresh  daily.  This  is  more  rapidly  made 
than  No.  i. 

Both  may  be  used  as  substitute  articles  of  diet,  plain  or 


PLATE  X 


Same  case  as  Plate  JX.  Diarrhea  more  advanced.  Note 
blood  and  mucus:  some  green  and  discoloration  by  bismuth. 
Very  little  milk  feces  present. 


FOOD   RECIPES.  145 

in  combination  with  white  of  egg,  egg-water,  cereal-water, 
or  a  small  amount  of  the  cereal  itself  may  be  added.  For 
older  children  celery  or  onion  flavoring  may  be  used. 

Expressed  Beef-juice. —  Cut  into  squares  one-fourth  to 
one-half  pound  of  fresh  lean  beefsteak.  Rump  or  round 
will  do.  Place  in  a  clean  pan  without  fat  or  butter,  and 
heat  until  the  pieces  of  meat  are  just  "whitened"  on  all 
sides.  Express  the  beef  "juice"  or  blood  with  a  clean 
lemon-squeezer.  Salt  to  taste.  Keep  on  ice.  Remove  fat. 
Give  infant  from  foss  to  f3ij  three  times  a  day  on  an  empty 
stomach.  Exactly  one-half  hour  before  feeding  is  tot  be 
preferred.  Before  feeding  it,  heat  by  placing  the  desired 
amount  in  a  spoon  and  holding  the  latter  over  some  steam. 
If  the  juice  changes  color  and  becomes  brown  it  has  been 
heated  too  much  and  must  be  discarded  for  other.  The 
purpose  of  heating  is  to  warm  it — not  to  cook  it,  otherwise 
the  purpose  for  which  it  was  given  will  be  lost.  Expressed 
beef -juice  should  be  fed  to  all  bottle  babies  after  the  second 
or  third  month,  and  should  be  continued  until  after  the 
nursing  period.  Most  infants  enjoy  it.  It  prevents,  and 
assists  in  curing  rickets  and  scurvy. 

Mutton-broth. — To  I  pound  of  fresh,  lean,  chopped 
mutton  add  i  quart  of  water.  Boil  one  hour.  Renew 
water  as  it  evaporates.  Strain.  Cool.  Remove  fat.  Salt 
to  taste.  Fresh  daily.  Warm  before  feeding.  Useful  in 
cases  of  diarrhea,  alone  or  in  combination  with  egg-albumin, 
cereal-water,  or  the  whole  cereal. 

Veal-broth. — Made  as  above,  substituting  veal.  Useful 
in  constipation. 

Chicken-broth. — To  every  pound  of  chicken  add  i  quart 
of  water.  Proceed  as  under  mutton-broth.  A  useful  sick- 
room delicacy,  alone  or  in  combination  as  above. 

10 


146  ARTIFICIAL   FEEDING. 

Squab-broth. —  To  one  freshly  killed  and  thoroughly 
cleaned  and  washed  squab,  add  sufficient  water  to  cover, 
and  a  handful  of  washed  celery  tops.  Boil  fromi  twenty 
minutes  to>  one-half  hour.  Strain.  Cool.  Remove  fat. 
Salt.  An  excellent  stimulant  to  the  appetite.  Useful  as  a 
change.  May  be  used  plain  or  in  combination  with  cereals, 
especially  well-cooked  rice. 

Vegetable-broth. — Thoroughly  wash  i  beet,  i  carrot,  a 
handful  of  spinach,  and  some  celery  tops.  Add  i  quart  of 
water.  Boil  until  vegetables  are  tender.  Strain.  Add 
sufficient  boiled  water  to  make  a  quart.  Salt  to  taste.  Use- 
ful as  a  laxative,  antacid,  antiscorbutic,  antirachitic,  or 
antiexudative. 

Creamed  Broths. — Any  of  the  broths  above  detailed  may 
be  creamed  or  thickened.  Rub  i  mediumhsized  tablespoon- 
ful  of  wheat-flour  into  a  smooth  paste  with  a  cupful  of  the 
cold  broth.  Add  remaining  portion  of  the  quart.  Bring 
to  boiling  point  with  constant  stirring.  Cool.  Salt  to  taste. 
Warm  before  using.  This  adds  to  the  bulk  and  nourish- 
ment of  the  broth  and  assists  in  its  constipating  effect. 

Burnt-flour  Soup. — Brown  i  tablespoonful  of  wheat- 
flour  in  a  clean  pan,  with  or  without  butter.  Add.i  quart  of 
water  and  bring  slowly  to  boiling  point  with!  constant 
stirring.  Salt  to  taste.  Very  useful  in  diarrhea  in  older 
children.  Fed  cool  or  warm. 

Beef-jelly. — To  i  pound  of  fresh,  lean,  chopped  beef  add 
i  pint  of  water.  Boil  one  hour.  Renew  water.  Strain. 
Salt  to  taste.  Allow  to  cool,  when  it  jellies.  A  sickroom 
delicacy. 

Rice. —  Wash  a  cupful  of  best  rice  several  times  with 
warm  water.  Add  sufficient  water  to  cover  it.  Boil  three 
hours.  Renew  water  from  time  to  time  as  needed.  Strain. 


FOOD   RECIPES.  147 

Salt  to  taste.  Rice  should  be  mushy.  Taken  with  milk, 
mutton-broth,  butter,  salt,  meat-juice,  or  sugar  and  cinna- 
mon. May  be  mixed  with  apple-sauce. 

Cornstarch. — Rub  2  tablespoonfuls  of  cornstarch  into  a 
smooth  paste  with  milk.  Heat  what  remains  of  I  quart  of 
milk.  Beat  up  2  eggs  well.  Add  the  hot  milk,  the  eggs, 
and  2  ounces  of  sugar  and  a  little  salt,  to  the  cornstarch 
paste.  Mix  well.  Bring  to  a  boil,  stirring  constantly. 

Cornmeal-gruel. — One-half  cupful  of  selected  yellow 
cornmeal  is  sprinkled  into  I  pint  of  hot  water  or  hot  milk. 
Salt  is  added.  Cook  for  one  hour  in  a  double  boiler. 

Arrowroot. — Rub  I  teaspoonful  of  best  arrowroot  into  a 
smooth  paste  with  little  milk.  Add  y2  pint  of  boiling  milk, 
meanwhile  stirring.  Cook  five  minutes  without  burning. 
Sweeten  and  salt  to  taste.  It  may  also  be  flavored  with 
vanilla  or  cinnamon,  etc. 

Arrowroot-water. — Add,  without  lumping,  I  teaspoonful 
•of  arrowroot  to  I  pint  of  water.  Boil  one-half  hour.  Re- 
new water  to  a  pint.  Salt  to  taste.  Useful  as  a  drink  plain 
or  flavored  with  vanilla  or  added  to  milk  as  a  diluent  to 
attenuate  the  curd. 

Cream  of  Wheat,  or  Farina. — Made  as  cornmeal-gruel. 

Stewed  Squab. — See  squab-broth,  page  146. 

Baked  Potato. — \Yash  a  large  potato  clean.  Dry. 
Punch  full  of  holes  with  a  fork.  Dampen  the  outside  and 
cover  with  salt.  Put  in  a  hot  oven  in  a  pan  in  which 
salt  has  been  placed;  Bake  quickly.  Break  open  at  once. 
Mash  and'  serve  with  milk,  butter,  or  beef-juice.  Salt  to 
taste. 

Spinach. —  Wash  spinach  ten  times  with  cold  water,  re- 
moving all  grit  and  worms.  Cover  with  water  to  which 
a  little  salt  has  been  added.  Cook  until  tender.  Place  in  a 


148  ARTIFICIAL   FEEDING. 

collander  to  remove  all  water.  Chop  very  fine  on  a  clean 
board.  Brown  a  little  flour  with  butter,  in  a  pan.  Stir  in 
the  spinach  until  hot.  A  little  milk  or  cream  may  be  added 
if  desired. 

Stewed  Celery. — Separate  stalks  of  celery.  Thoroughly 
wash.  Cut  stalks  into  small  pieces.  Cover  with  slightly 
salted  water.  Stew  until  tender.  Pour  off  water.  Add  a 
little  plain  milk  or  milk  to  which  a  little  flour  has  been 
added.  Add  a  small  piece  of  butter,  dash  of  salt  and  pep- 
per. Heat  to  boiling. 

Stewed  Onions. —  Pare  young  onions  of  medium  size, 
then  prepare  as  celery. 

Coddled  Eggs. —  Place  a  fresh  egg  in  boiling  water. 
Remove  from  fire.  Allow  egg  to  remain  immersed  two 
minutes.  Open  at  once. 

Egg-water. — The  white  of  I  fresh  egg,  beaten  slightly, 
is  added  to  i  pint  of  cool  water.  Shake  well.  Strain. 
Salt  and  sweeten,  if  desired,  to  taste.  Feed  plain  or  with 
cereal-waters,  or  beef -juice. 

Toast-water. — Pour  I  pint  of  boiling  water  over  I  large 
piece,  of  well-browned  toast  made  of  stale  bread.  Stand 
five  minutes.  Strain.  Salt  to  taste.  Useful  in  diarrhea, 
given  cold  or  hot. 

Lime-water. —  Piece  of  unslacked  lime  size  of  a  walnut. 
Cover  with  water  and  mix  well  until  thoroughly  slacked. 
Allow  to  stand  twenty-four  hours.  Decant.  Filter. 

Junket. — Warm  i  pint  of  milk,  flavored  with  vanilla,  if 
desired,  to  about  100°  F.  Divide  into  small'  glasses  or 
cups.  Stir  quickly  into  each  l/4  teaspoonful  of  liquid 
rennet  or  Fairchild's  essence  of  pepsin,  If  it  be  desired 
not  to  divide  into  glasses,  the  milk,  sugar,  flavoring,  and 
ferment  (f3j  to  fSij  to  the  pint)  may  be  mixed  together 


FOOD   RECIPES.  149 

and  the  whole  heated  to  100°  F.  in  a  double  boiler.  Re- 
move and  place  on  ice  as  soon  as  clotting1  occurs. 

Baked  Apples. — Wash  apples  well.  Core  them.  Fill 
holes  with  sugar,  and,  if  desired,  a  small  piece  of  butter. 
Place  in  a  pan,  with  a  little  water.  Bake  until  soft.  Serve 
plain  or  with  cream  and  sugar.  A  useful  dessert. 

Orange-juice. —  Slice  an  orange  in  half.  Remove  juice 
by  hard  pressure  or  lemon-squeezer.  Strain  to  remove 
seeds  and  pulp.  Given  cold  on  an  empty  stomach.  Anti- 
scorbutic and  laxative. 

Prune-water. — Wash  a  pound  of  prunes  clean.  Cover 
with  water.  Boil  one  hour.  Renew  water  of  evaporation. 
Add  no  sugar.  Strain.  Laxative,  antiscorbutic.  Sugar 
may  be  added  if  desired.  The  prune-pulp  is  also  a  good 
laxative  for  older  children. 

Acacia-water. — Pour  i  pint  of  boiling  water  over  I 
ounce  of  gum  arabic  and  agitate  until  dissolved.  Strain. 
May  be  used  plain,  cool,  or  be  flavored  with  sugar,  salt, 
orange-  or  lemon-  juice.  A  small  amount  of  brandy  may 
also  be  added.  Demulcent,  febrifuge,  thirst  quencher. 

Gelatin. — Soak  the  contents  of  I  small  package  of 
Knox's  gelatin  for  one  hour  in  just  enough  water  to  cover 
it.  Add  i  quart  of  boiling  water.  Stir  until  dissolved. 
Pinch  of  salt.  Flavor  with  sherry  wine,  vanilla,  or  fruit- 
juice.  Add  sugar  to  the  proper  degree  of  sweetness.  Set 
away  to  cool  and  thicken.  A  useful,  cooling  dessert.  Has 
no  nutritive  value,  but  is  filling  and  satisfying. 

Zweiback  may  be  made  by  rebaking  stale  bread  or  cake, 
or  it  may  be  purchased.  It  is  a  useful,  easily  digestible 
foodstuff,  and  is  slightly  laxative.  It  may  be  served  dry  or 
with  butter,  or,  more  commonly,  with  hot  water  and  sugar. 

Holland  Rusk  may  be  used  as  zweiback. 


CHAPTER  IV. 

INFANTILE  ATROPHY. 

Synonyms. —  Marasmus,  Essential  Marasmus,  Decom- 
position, Infantile  Wasting,  Baby  Consumption,  Athrepsia. 

Definition. — Marasmus  should  include  only  those  cases 
of  gradual  but  progressive  loss  of  weight  which  depend 
upon  the  faulty  assimilation  of  a  food,  faulty  for  the  in- 
dividual and  administered  over  a  comparatively  prolonged 
period  of  time.  All  other  instances  of  wasting  occurring  in 
infants  are  symptomatic  of  more  or  less  tangible  causes. 

PATHOLOGY. 

In  essential  or  dietetic  marasmus  there  are  neither  gross 
nor  microscopic  demonstrable  lesions  which  account  for  the 
symptoms.  A  further  discussion  as  to  the  findings  in  a  case 
dead  from  this  disease  would  be  time  consuming  and  of  no 
practical  value.  Those  cases  which  exhibit  tuberculosis, 
syphilis,  chronic  suppuration,  acute  sepsis  of  the  newborn, 
obstructive  pyloric  disease  or  chronic  meningitis,  are  not 
essential  marasmus,  but  simply  instances  of  wasting  which 
are  dependent  upon  any  one  of  the  factors  aforementioned. 

ETIOLOGY. 

Predisposing  Causes. — Improper  artificial  feeding  is  re- 
sponsible for  the  majority  of  cases.  It  usually  follows  the 
causeless  withdrawal  of  the  breast.  Marasmus  is  rarely,  if 
ever,  met  in  the  breast-fed.  Personally  I  have  never  seen  a 
case.  Diarrheal  diseases  in  the  artificially  reared,  especially 
in  those  cases  encountered  in  the  summer  months,  often  are 
(150) 


ETIOLOGY.  151 

responsible  for  such  an  impaired  nutritional  state  that  the 
degree  of  food  tolerance  does  not  again  extend  beyond  the 
minimum  quantity,  or  at  least  does  not  reach  the  optimum 
amount  necessary  to  sustain  life  and  to  prorvide  for  gain. 
Many  of  these  cases  develop  marasmus  because  the  func- 
tional activity  of  the  glands  of  the  gastrointestinal  tract  has 
been  so  perverted  that  no  food  could  subsequently  be  found 
which  could  again  properly  activate  them  to  produce  normal 
ferments.  Hence  normal  digestion  could  not  occur  and 
assimilation  of  improper  end-products  was  the  final  result. 
Recovery  cannot  ensue  unless  the  proper  food  is  found  to 
normally  activate  these  perverted  glands. 

Poverty  and  improper  hygienic  surroundings,  vitiated 
atmosphere,  personal  neglect,  and  overcrowding  are  predis- 
posing factors  of  prime  importance,  especially  when  com- 
bined .with  impro'per  and  irregular  nourishment.  Infants 
upon  the  breast  will  stand  a  wonderful  amount  of  abuse 
and  neglect.  Remarkable  specimens  of  babyhood  are  fre- 
quently encountered  in  the  slums.  These  infants  thrive  in 
spite  of  filth  and  poverty,  retaining  in  many  instances  the 
one  human  heritage  of  which  a  perverted  and  selfish  social 
system  cannot  rob  them — the  milk  from  their  mothers' 
breasts. 

Complete  the  theft — deprive  these  poverty-stricken 
babies  of  human  milk — and  the  joined  forces  of  artificial 
feeding  and  squalor  will  produce  numberless  cases  of 
marasmus  and  fill  many  unnecessary  graves — permanent 
monuments  of  disgrace  to  our  present-day,  much-vaunted, 
but  barbaric  civilization !  It  is  not,  however,  to  be  assumed 
that  marasmus  is  not  met  among  the  rich.  Here  idleness, 
indolence,  indifference,  hysteria,  selfishness,  and  ignorance, 
as  surprising  as  it  is  common,  deprive  many  an  infant  of  the 


152  INFANTILE  ATROPHY. 

better  class,  so  called,  of  its  rightful  heritage  of  breast 
feeding. 

The  baneful  results  of  overcrowding  and  of  artificial 
feeding  are  nowhere  better  illustrated  than  in  hospitals  for 
infants.  These  babies  do  not  receive  a  sufficient  comple- 
ment of  fresh  air.  It  is  an  impossibility  for  a  nurse  in 
charge  of  five  or  six  babies,  however  willing  she  may  be,  to 
attend  promptly  to  the  personal  and  physical  wants  of  her 
charges.  Many  of  these  babies  do  not  receive  their  food 
properly  warmed  or  the  bottle  is  not  held  for  them,  and  con- 
sequently the  food  becomes  cold  or  the  infant  falls  asleep 
with  the  meal  unfinished,  and  the  fact  is  not  discovered  until 
the  time  for  the  next  feed  arrives.  The  attending  physi- 
cian either  can  not  or  does  not  study  carefully  the  individual 
nutritional  demands  or  the  peculiar  digestive  capacities  of 
his  charges.  In  a  word,  these  babies  lack  mothering  and 
detailed  care,  and  they  cease  to  gain.  They  lose,  and 
speedily  there  is  developed  marasmus. 

Ignorance  as  to  the  adaptability  of  the  individual  diges- 
tive apparatus  to  the  various  food  elements  may,  on  the 
part  of  the  would-be  dietitian,  lead  to  serious  digestive  dis- 
orders which  will  eventuate  in  a  perverted  metabolism  and 
marasmus.  Thus,  one  infant  may  exhibit  protein  intoler- 
ance, another  will  be  disturbed  by  fat,  and  yet  another  by 
sugar.  Starch,  fed  in  excess  or  over  a  prolonged  period  or 
exhibited  without  the  additional  food  elements  (protein, 
fat,  sugar),  may  lead  to  such  injury  of  the  gastrointestinal 
mucosa  as  to  prevent  the  proper  assimilation  of  food.  This 
is  especially  noted  after  summer  diarrhea,  where  patients 
are  for  long  periods  kept  upon  cereal-waters  (barley,  rice, 
oatmeal)  without  the  addition  of  milk  (Mehlnahrschaden — 
Czerny  and  Keller) .  Scrutiny  of  the  stools  and  the  charac- 


ETIOLOGY.  153 

ter  of  the  symptomatology  presented  by  the  digestive  organs 
will  enable  the  practitioner  to  decide,  in  most  instances,  upon 

• 

the  mischief -making  factor.  (See  Chapter  II,  page  104.) 
Age  in  itself  has  no  direct  influence  on  the  incidence  of 
this  disease,  although  most  cases  begin  under  i  year.  After 
dentition  has  proceeded  to  the  appearance  of  five  or  six 
teeth  the  possibility  of  marasmus,  unless  unusual  circum- 
stances obtain,  is  extremely  rare.  Sex  and  race  have  no 
influence.  Prematurity,  usually  associated  with  an  unde- 
veloped gastrointestinal  mucosa  and  a  deficient  glandular 
system,  leads  to  digestive  difficulties,  at  times  insurmount- 
able, and  upon  these  depends  the  development  of  marasmus. 
Exciting  Cause. — This  is  at  present  unknown.  Many 
theories  have  been  advanced,  but  none  has  received  univer- 
sal acceptance.  The  depressed  nutritional  state  and  dimin- 
ished food  tolerance  probably  result  from  a  perverted  body 
chemistry — a  disturbed  metabolism  wherein  the  calories  can- 
not be  supplied  to  the  individual  in  a  digestible  form  so  as 
to  provide  for  growth  as  well  as  to  maintain  body  tempera- 
ture and  tissue  balance.  Hence  downtear  exceeds  upbuild, 
and  the  individual  commences  to  feed  upon  his  own  stored 
tissues  to1  furnish  sufficient  calories  to  sustain  life.  This 
perverted  metabolism  may  be  produced  by  an  initially  per- 
verted activation  of  the  salivary  glands  by  a  food  improper 
for  the  individual.  Thus  results  successively  perverted 
activation  of  all  the  glands  of  the  gastrointestinal  tract. 
This  idea  may  be  amplified  as  follows : — 

When  the  adult  sees,  thinks  of,  or  tastes  wholesome  food, 
the  functional  activity  of  the  salivary  glands  is  inaugurated. 
This  phenomenon,  commonly  known  as  "mouth  watering," 
occurs  as  the  result  of  stimulation  of  the  nervous  mechan- 
ism of  the  glands  as  the  result  of  psychic  or  physical  impulses 


154  INFANTILE   ATROPHY. 

transmitted  through  the  sympathetic  or  sensory  system.  It 
may  be  assumed  that  this  normal  stimulation  results  in  the 
elaboration  of  a  saliva  normal  in  every  respect  and  capable 
O'f  acting  normally  upon  a  normal  food.  The  food  thus 
prepared  is  swallowed.  As  the  result  of  normal  salivary 
digestion  upon  normal  food,  end-products,  themselves  nor- 
mal in  every  respect,  are  formed.  The  entrance  of  these 
normal  end-products  into  the  stomach  is  responsible  in  turn 
for  the  normal  activation  of  the  glands  of  the  gastric  mucosa. 
These  therefore  produce  a  gastric  secretion  also  normal. 
This,  acting  upon  the  partially  digested  food,  and  end-prod- 
ucts of  the  salivary  digestion,  converts  the  whole  into  still 
further  normal  end-products  characteristic  of  this  stage  of 
the  digestive  process.  These,  entering  the  duodenum,  nor- 
mally activate  the  pancreas  and  the  liver,  causing  these 
glands  to  elaborate  their  secretions  in  no  way  perverted. 
These  now  continue  their  normal  action  upon  the  remaining 
food  and  end-products  normal  to  this  stage  of  digestion.  The 
final  whole  now  enters  the  intestines,  the  glands  of  which 
are  normally  stimulated  likewise  to  produce  a  normal  secre- 
tion which,  again  acting  upon  normal  end-products,  finally 
completes  the  process  of  digestion  by  the  conversion  of  all 
remaining  food  and  normal  end-products  into  normal  final 
products,  which,  absorbed  by  the  normal  intestinal  mucosa, 
eventually  reach  the  blood  and  tissues  via  liver  and  thoracic 
duct,  and  these,  being  normal  in  every  way,  not  only  pro- 
vide for  tissue  upbuild  and  downtear,  but  for  growth  as 
well. 

Now  let  us  consider  the  reverse.  The  mere  sight  or 
smell,  not  alone  the  taste,  of  abnormal  or  unwholesome  food 
(abnormal  or  unwholesome  for  the  individual),  not  only 
perverts  the  salivary  secretion,  causing  an  inhibition,  but 


ETIOLOGY.  155 

may  even  cause  serious  gastric  and  intestinal  disturbances 
resulting  at  times  in  vomiting  and  diarrhea.  In  other  words, 
if  we  substitute  the  word  unwholesome  for  wholesome  and 
abnormal  for  normal  in  the  statements  of  the  preceding 
paragraph,  we  may  assume  an  hypothesis  not  at  all  unlikely 
in  its  applicability  to  the  etiology  of  infantile  atrophy. 
Primary  abnormal  stimulation  by  an  unwholesome  food 
produces  the  initial  abnormal  secretion  and  resulting  abnor- 
mal end-product  which,  acting  upon  the  whole  line  of  gastric 
and  intestinal  glands,  are  the  essential  factors  causing  the 
production  of  abnormal  secretions  and  end-products  at  each 
stage  of  the  digestive  process.  Each  abnormal  end-product 
is  responsible  for  the  initiation  of  the  abnormal  glandular 
activation  in  each  step  following.  The  final  product,  when 
the  end  of  the  digestive  process  is  reached,  is  abnormal  for 
the  individual — does  not  nourish  him,  i.e.,  not  only  is  down- 
tear  and  upbuild  not  secured,  but  growth  is  not  inaugurated. 
Therefore  the  individual  feeds  upon  his  own  tissues,  loss 
ensues — atrophy,  malnutrition,  marasmus — decomposition 
becomes  apparent. 

That  this  is  theory  cannot  be  combated.  That  it  may  be 
sustained  by  clinical  facts  and  circumstantial  data  is  also 
true.  One  common  clinical  experience  is  sufficient  to  war- 
rant its  consideration.  These  cases  of  atrophy  present 
neither  a  gross  nor  a  microscopic  anatomy  as  stated.  No 
perverted  or  diseased  state  of  the  gastrointestinal  mucosa  is 
discernible.  Therefore  the  productive  element  must  reside 
in  the  food  itself.  In  fact,  it  must  be  the  food  itself !  This 
is  substantiated  by  many  cases  which  have  run  the  gamut  of 
formulas,  food  mixtures,  and  a  score  of  physicians  and  pedi- 
atrists,  reduced  to  actual  skin  and  bone,  are  commonly  re- 
vived by  the  substitution  of  proper  food  (proper  for  the 


156 


INFANTILE   ATROPHY. 


individual).  In  the  majority  of  instances  this  food  is  breast 
milk  or  a  fortunately  thought-out  milk  adaptation.  In 
other  words,  the  cause  and  cure  of  the  condition  have  been 
determined  on  the  instant  from  which  the  infant  commences 
to  thrive — the  proper  food  has  been  substituted  to  produce 
normal  activation  of  the  salivary  glands  initially,  from  which 
will  follow  in  succession  normal  activation  of  the  stomach, 
the  pancreas,  liver,  and  intestines.  The  end-product  is  cor- 
rect and  upbuild  exceeds  downtear.  The  tide  is  turned  and 
the  infant  thrives.  In  other  words,  the  etiology  of  infant 


Fig.  26. — Essential  marasmus. 

atrophy  is  the  continuous  use  of  a  food  faulty  for  the  indi- 
vidual, and  its  successful  therapy  consists  in  finding  the 
proper  food  for  the  individual — a  responsibility  often  more 
readily  stated  than  accomplished,  and  yet  withal,  the  con- 
ditio  sine  qua  non. 

SYMPTOMS. 

The  clinical  picture  of  infantile  marasmus  is  typical  and, 
when  once  seen,  is  indelibly  impressed  upon  the  memory. 
It  must  be  remembered,  however,  that  other  conditions  will 
bring  about  a  state  of  wasting  identical  in  all  appearances 
to  that  which  we  now  understand  as  essential  dietetic  maras- 
mus. These  infants  (Figs.  26,  27,  and  28)  appear  senile, 


SYMPTOMS.  157 

weazened,  and  shrunken.  The  entire  face,  including  the 
forehead,  is  wrinkled.  The  wrinkles  are  intensified  by  crying 
and  surrounding  the  mouth  they  assume  the  form  of  a 
parenthesis.  The  features  are  pointed.  The  cheek-bones 
are  prominent.  The  eyes  commonly  appear  large  and 
bright.  There  is  an  absence  of  fat  in  the  orbit.  This  causes 
the  eyeballs  to  recede.  Later  the  eyes  may  be  covered  by 
a  thick  scum  of  mucus.  The  tongue  is  often  clean  and  pre- 
sents a  bright-red  surface  with  swollen  papillae.  It  may  be 


Fig.  27. — Essential  marasmus. 

covered  with  milk-curds,  or  thrush.  The  buccal  mucosa  is 
pale.  The  sucking  pads  remain  after  every  other  vestige  of 
subcutaneous  fat  is  lost.  The  skin  hangs  in  folds  upon  the 
arms  and  legs,  especially  at  the  axillae  and  on  the  inner 
aspects  of  the  thighs.  The  skin  may  be  muddy  and  dark, 
or  may  be  unusually  transparent.  The  skin  over  the  but- 
tocks may  be  intact,  but  is  often  excoriated.  These  infants 
move  their  arms  and  legs  slowly,  sometimes  appearing  to  do 
so  with  deliberation.  On  the  other  hand,  they  may  lie 
quietly  in  their  cribs,  unless  disturbed.  In  the  beginning 
the  cry  is  strong.  Later  it  becomes  whiny  and,  in  fatal 
cases,  just  preceding  dissolution,  it  may  be  hoarse  and 
weak.  The  skin  of  the  abdomen  is  loose  and  may  be 


158  INFANTILE   ATROPHY. 

readily  wrinkled  when  gathered  between  the  thumb  and 
forefinger,  on  account  of  the  loss  of  subcutaneous  fat.  The 
belly  is  often  distended.  If  these  infants  are  laid  naked  upon 
their  backs  and  their  legs  extended,  they  give  the  appearance 
of  a  frog — wide  abdomen,  narrow  hips,  and  skinny  legs 
(Fig.  29). 

The  temperature  is  subnormal.  This  is  an  important 
diagnostic  point.  The  pulse  is  normal.  It  may  become  weak 
and  rapid. 


Fig.  28. — Marasmus.    Characteristic  attitude  and  appearance.    Poor 
circulation  shown  by  cyanosis  of  feet. 

Vomiting  is  a  rare  symptom.  It  is  not  an  essential  feat- 
ure of  the  nosology  of  marasmus.  It  may  result  from  an 
acute  digestive  disturbance  or  indicate  the  effect  of  a  tangible 
etiologic  factor,  viz.,  excessive  fat  or  sugar  feeding  (exces- 
sive for  the  individual).  The  bowels  move  from  once  to 
five  times  a  day.  The  movements  usually  appear  well 
digested.  Often  they  are  green  and  contain  mucus  and 
curds.  This  follows  a  dietary  indiscretion.  If  fat  has  been 
fed  in  excess,  they  are  greasy.  The  fat  is  recognized  by  its 
response  to  its  various  tests  (Chapter  I,  page  33).  The 
movements  may  be  constipated  and  greasy,  loose  and  greasy, 


SYMPTOMS. 


159 


Fig.  29. — Frog  appearance  in  essential  marasmus.  Note  the  wide 
and  prominent  belly,  the  narrow  hips  and  skinny  legs.  This  descrip- 
tion is  original  with  the  author  and  has  been  of  material  assistance  to 
him  in  teaching. 


160  INFANTILE  ATROPHY. 

hard  and  friable,  or  may  contain  soap  (Plate  VII).  If  the 
curds  be  protein  they  respond  readily  to  the  tests  for  this 
substance  (Chapter  I).  The  stool  is  neutral  or  alkaline. 
Where  excessive  quantities  of  sugar  are  fed,  the  movements 
are  watery  and  usually  acid  and  excoriate  the  anal  region. 

The  urine  in  most  cases  is  normal.  It  may  be  concen- 
trated and  deposit  urates  and  uric  acid  upon  the  diaper.  In 
some  constipated  cases  receiving  too  much  fat  it  is  ammoni- 
acal. 

The  blood  exhibits  the  evidences  of  a  symptomatic  ane- 
mia, and  may  appear  unduly  concentrated,  the  clotting  time 
being  shortened. 

These  babies  often  have  a  voracious  appetite,  sucking 
vigorously  upon  whatever  is  placed  within  their  mouths. 
They  frequently  suck  constantly  upon  the  hand  until  the 
fingers  become  macerated  and  sore  (Fig.  27).  The  stomach 
is  dilated  and  may  present  undue  miotility.  The  heart  and 
lungs  present  no>  abnormalities. 

Where  excessive  starch  (for  the  individual)  causes  the 
injury  to  the  gastrointestinal  mucosa  (see  Etiology,  page 
152),  a  peculiar  type  of  atrophic  infant  is  presented.  The 
muscles  are  hypertonic.  The  tissues  are  dry  and  atrophied. 
The  bowels  are  loose,  the  abdomen  is  distended,  and 
anemia  is  marked.  The  etiologic  factor,  as  provided  by  a 
history  of  prolonged  starch  feeding,  must  in  this  instance 
be  known  in  order  to  conclude  a  proper  diagnosis  and  to 
provide  a  proper  therapy,  viz.,  the  exhibition  of  breast  milk 
or  of  properly  adapted  cows'  milk,  and  the  exclusion  of 
starch,  at  least  for  the  time  being.  It  must  be  remembered, 
however,  that  there  are  cases  wherein  an  excessive  starch 
diet  is  associated  with  an  unusual  increase  in  weight,  due  to 
the  retention  of  water  in  the  system.  These  babies  are  fat, 


SYMPTOMS.  161 

doughy,  and  present  a  tendency  to  secondary  infection, 
cornea!  ulceration,  bronchopneumonia,  and  skin  lesions. 
Edema,  unassociated  with  nephritis,  is  not  uncommon,  and 
depends  upon  hydremia  (Fig.  30).  If  starch  is  withdrawn 
and  milk  added  to  the  feeds,  these  infants  lose  weight.  In 
the  first  instance,  however,  the  loss  is  only  temporary.  A 
second  and  permanent  gain  is  inaugurated  finally  when  the 
gastrointestinal  mucosa  assumes  its  normal  state.  Those 


Fig.  30. — Marasmus  complicated  by  edema.  Note  the  pits  from 
pressure  on  the  lower  leg  and  thigh  and  also  the  edema  of  the  de- 
pendent portion  of  the  abdomen  and  of  the  face. 

cases  which  present  corneal  ulcerations  are  frequently  fatal 
(Czerny). 

In  yet  another  type,  where  atrophy  is  associated 
with  hypertonicity,  the  physical  appearance  is  not  unlike 
that  of  tetany.  The  muscles  are  rigid  and  boardlike  and  the 
electrical  excitability  is  materially  increased.  The  head  is 
often  retracted.  The  stools  frequently  respond  to  the 
starch  test  with  iodine. 

The  weight  curz>e  exhibits  a  gradual  depression  in  all 

cases  of  marasmus.     From  5  to  6  ounces  per  week  is  the 

11 


162  INFANTILE   ATROPHY. 

usual  record  of  loss.  At  times  there  may  be  a  week  or  two 
when  the  weight  does  not  fall,  bait  remains  stationary,  or 
there  may  be  a  gain  of  an  ounce  or  two.  Sudden  losses 
are  not  common  unless  there  occurs  an  attack  of  diarrhea 
or  some  other  complication.  Where  edema  is  present,  espe- 
cially in  moribund  cases,  a  sudden  rise  in  weight  may  be 
recorded.  This  should  always  be  borne  in  mind,  so>  that  the 
mistake  may  not  be  made  of  regarding  it  as  a  turn  for  the 
better.  In  cases  which  do  not  recover,  the  loss  in  weight 
usually  proceeds  to  the  point  where  the  infant  averages  be- 
tween 6  and  7  pounds.  It  is  also  noted  in  some  cases  that 
when  once  the  proper  food  is  found,  or  a  change  is  made 
from  one  formula  to- another,  a  rapid  gain  of  from  6  to  10 
ounces  may  be  recorded  within  forty-eight  or  seventy-two 
hours.  The  infant  shows  marked  evidences  of  improve- 
ment in  every  way.  After  a  week  or  two,  however,  the 
usual  gain  is  from  3  to  8  ounces  per  week. 

COMPLICATIONS. 

Sudden  and  unexpected  death  may  occur  in  these  little 
babies  when  their  condition  seems  to  be  no  worse  than  it  had 
been  for  some  weeks  previously.  The  spark  of  life  has  been 
fluttering  foil  some  time  when,  unexpectedly  but  quietly, 
the  supply  of  fuel  having  been  exhausted,  without  struggle, 
it  gradually  ceases  to  burn  and  life  is  extinct.  This  fre- 
quently happens  during  the  night,  and  the  infant  is  found 
dead  in  bed  in  the  morning.  Hypostatic  pneumonia  may 
develop  as  a  terminal  evidence  of  feeble  circulation  and  of 
lying  in  the  prone  position  for  a  long  time.  These  infants 
are  susceptible  to  cold,  chilling  of  the  surface,  and  to  sudden 
changes  in  temperature.  Hence  colds,  rhinitis,  bronchitis, 
and  bronchopneumonia  occur.  All  are  poorly  borne  and 


COMPLICATIONS.  163 

frequently  determine  a  fatal  outcome.  Purpura,  affecting 
the  skin  of  the  lower  thorax  and  abdomen,  and  appearing  as 
a  thickly  scattered,  fine  eruption,  occurs  from  two  to  three 
weeks  before  death,  in  many  cases.  I  have  never  seen  a  re- 
covery in  which  this  symptom  appeared.  Should  these 
cases  develop  an  acute  diarrheal  condition,  accompanied  by 
severe  straining,  inguinal  hernia  may  appear.  In  one  case 
under  my  care,  strangulation  of  a  hernia  occurred,  and 
was  successfully  operated  upon  by  Dr.  Stillwell  C.  Burns. 
From  the  same  cause  prolapsus  ani  develops,  and  may  be  a 
troublesome  though)  usually  not  a  dangerous  issue.  Anal 
excoriation  and  severe  irritation  of  the  entire  buttock  may 
seriously  incommode  the  infant  and  interfere  with  its  quiet. 
Stomatitis  and  thrush  are  usually  directly  dependent  upon 
faulty  technique  in  the  antiseptic  toilet  of  the  mouth.  Der- 
mal irritations  of  all  varieties,  bed-sores,  macerations,  inter- 
trigo,  furunculosis,  acute  dermatitis  and  erysipelas  are 
avoidable,  troublesome  and  sometimes  dangerous  occur- 
rences in  poorly  kept  cases.  Edema  occurs  without  nephritis 
and  is  an  exceptionally  interesting  phenomenon,  since  its 
etiology  is  obscure  (Fig.  30).  It  has  been  already  re- 
ferred to  as  being  responsible  for  a  sudden  increase  in  the 
weight.  It  appears  first  in  the  extremities  and  is  a  terminal 
state.  It  spreads  upward  and  may  involve  the  abdominal 
wall  or  the  entire  body.  The  temperature  is  very  much 
below  no'imal  and  the  urine  is  clear,  limpid,  and  free  of 
casts  and  albumin.  Its  supposed  association  with  injury 
of  the  intestinal  mucosa  by  starch  (Mehlnarschaden)  has 
been  previously  noted.  Its  dependence  upon  the  retention 
of  fluid  within  the  tissues,  on  account  of  the  presence  of 
sugar  and  salt  in  them,  has  been  maintained  by  some 
authors.  Although  in  most  instances  indicating  a  fatal 


164  INFANTILE   ATROPHY. 

outcome,  I  have  seen  this  symptom,  contrary  to  the  fore- 
going view,  entirely  disappear  following  the  daily  injection, 
subcutaneously,  of  warm  normal-salt  solution.  Sclerema 
and  sclerodcrma  may  occur  as  prelethal  conditions.  Scurvy 
and  rickets  may  be  met  as  the  result  of  carelessness  in  feed- 
ing proprietary  foods  or  boiled  preparations  over  too  long  a 
period  of  time  without  taking  proper  precautions. 

DIAGNOSIS  AND  DIFFERENTIAL  DIAGNOSIS. 

This  must  be  made  entirely  by  the  exclusion  of  all  other 
causes  of  wasting.  There  is  usually  a  history  of  the 
groundless  discontinuance  of  the  breast,  and  the  feeding  in 
rapid  succession  of  various  milk  formulas  and  a  host  of 
proprietary  foods,  some  of  which  may  agree  and  cause  a 
temporary  gain  in  weight.  The  mere  presence  of  wasting 
does  not,  as  we  now  understand  it,  necessarily  mean 
marasmus.  In  my  experience,  the  most  common  error  in 
this  connection  is  to  regard  wasting  dependent  upon  hid- 
den chronic  suppuration  and  wasting  dependent  upon 
pyloric  obstruction  as  marasmus.  As  an  instance  of  the 
first  circumstance  there  appeared  at  my  clinic  at  the 
Lebanon  Hospital,  some  years  ago,  an  infant  16  months  of 
age,  wasted  to  skin  and  bone,  in  whom  the  diagnosis  of 
marasmus  had  been  made.  The  age  of  the  child — 16 
months — and  the  presence  of  teeth  led  to  the  thought  that 
some  factor  other  than  a  dietetic  error1  was  operative. 
Fever  and  leucocytosis  were  absent.  A  careful  physical 
examination  led  to  the  diagnosis  of  encysted  empyema, 
which  was  verified  by  exploratory  puncture.  Operation  was 
followed  by  complete  recovery  within  three  months,  In 
this  case  the  absence  of  fever  and  of  leucocytosis,  and  also 
of  a  careful  examination,  in  all  probability  caused  the 


DIAGNOSIS  AND  DIFFERENTIAL  DIAGNOSIS.         165 

empyema  to  be  ignored.  The  two  former  were  absent  no 
doubt  on  account  of  the  fact  that  the  infant's  strength  and 
resisting  power  had  been  so  vitally  reduced  that  neither  the 
heat  centres  nor  the  leucocytes  could  any  longer  be  stimu- 
lated by  the  toxins  of  the  invading  organisms;  or  the  sys- 
tem had  become  immune  to  this  particular  bacterium,  for 
the  condition  had  in  all  probability  lasted  for  months.  The 
age  of  the  child,  presence  of  teeth,  and  the  previous  history 
of  a  pneumonia  should  have  led  to  a  careful  physical  ex- 
amination, if  to  nothing  else. 

I  have  seen  wasting  due  to  other  forms  of  chronic  sup- 
puration— double  otitis  media  of  long  standing,  chronic 
mastoid  disease,  pulmonary  abscess — diagnosed  as  simple 
marasmus  and  treated  by  formula.  In  one  instance,  in  which 
death  ensued,  a  fatal  issue  could  have  been  avoided  if  the 
importance  of  the  primary  underlying  factors  had  been 
appreciated.  The  mere  mention  of  these  facts  should  be 
sufficient  to  prevent  the  careful  practitoner  from  falling  into 
error. 

I  have  seen  24  or  more  cases  of  pyloric  obstruction  of  one 
type  or  another,  and  in  each  instance  save  2  was  the  diag- 
nosis of  marasmus  made.  This  is  a  grievous  error,  since 
non-surgical  or  surgical  treatment  will  save  the  majority 
of  these  cases  if  they  are  promptly  recognized.  In  maras- 
mus, vomiting  is  rare.  In  pyloric  obstructive  disease,  it  is 
a  prominent  and  early  feature,  propulsive  in  character,  and 
occurring  without  apparent  cause.  It  is  especially  sugges- 
tive in  breast-fed  babies,  occurring  immediately  or  a  few 
weeks  after  birth.  This  vomiting  is  usually  responsible  for 
taking  these  babies  from  the  breasts,  and  this  fact  in  itself 
should  always  arouse  suspicion.  In  pyloric  disease,  inquiry 
will  determine  that  the  bowel  movements  are  constipated, 


166  INFANTILE   ATROPHY. 

exceedingly  small,  infrequent,  or  entirely  absent.  Visible 
gastric  peristaltic  waves  are  present.  The  pylorus  is  fre- 
quently palpable.  The  administration  of  10  grains  of  char- 
coal is  followed  by  its  delayed  or  non-appearance  in  the 
anal  discharges  and  its  recovery  in  the  water  following 
stomach  wasting  twenty-four  hours  later.  The  X-ray  gives 
valuable  information  not  only  as  to  the  presence  of  obstruc- 
tion, but  also  as  to  the  degree  of  patency  of  the  pyloric 
orifice,  although  this  examination  is  not  essential  to  an 
accurate  clinical  diagnosis.  In  conclusion  it  may  be  stated 
that  the  only  symptoms  which  pyloric  disease  has  in  com- 
mon with  marasmus  are  the  progressive  wasting  and  the 
subnormal  temperature. 

Tuberculosis  may  be  a  cause  for  wasting.  The  term 
"babies'  consumption"  may,  with  propriety,  be  applied  to 
this  condition,  but  not  to'  "marasmus."  Both  terms  are 
regarded  by  many  of  the  laity  as  synonymous  and,  conse- 
quently, this  idea  is  responsible  not  only  for  much  con- 
fusion, but  also  for  much  unnecessary  fear.  Tuberculosis 
will  be  discovered  by  careful  investigation  of  the  lungs, 
glands,  and  bones  in  particular.  Fever  is  a  common  possi- 
bility, but  may  be  absent.  A  careful  rontgenographic  ex- 
amination of  the  bronchial  nodes  may  determine  these  to  be 
tubercular  and  a  cause  for  the  wasting.  The  abdomen 
should  also  be  thoroughly  palpated  for  enlargements,  and 
the  result  of  a  carefully  performed  von  Pirquet  or  Moro 
test  should  not  be  ignored  in  coming  to  a  correct  conclusion. 

Syphilis,  without  skin  lesions,  especially  in  the  very 
young,  causes  not  a  few  infants  to  rapidly  shrivel  and  in 
outward  aspect  they  closely  resemble  marasmus.  At  pres- 
ent the  Wassermann  test  is  of  much  value  in  detecting  these 
cases.  In  other  instances,  where  this  cannot  be  made,  re- 


DIAGNOSIS  AND  DIFFERENTIAL  DIAGNOSIS.         167 

liance  must  be  placed  upon  the  history  of  frequent  miscar- 
riages, lesions  upon  the  mother  or  father  or  both,  or  the 
appearance  upon  the  infant  of  copper-colored  eruptions, 
mucous  patches  around  the  anus  or  in  the  mouth,  or  of 
rhagades  (cracks)  about  the  corners  of  the  mouth,  and  a 
chronic  nasal  discharge  (snuffles),  together  with  the  com- 
mon enlargement  of  one  or  both  epitrochlear  glands. 

Acute  but  sluggish  sepsis  of  the  newborn,  manifesting 
itself  by  slowly  forming  metastatic  abscess — e.g.,  infection 


1 


Fig.  31. — Atrophy  or  marasmus  due  to  chronic  cerebrospinal 
meningitis. 

of  the  umbilical  stump,  retroumbilical  abscess,  peritonitis  in 
the  newborn  following  navel  infection — is  often  associated 
with  a  shrivelling  up  process  that  gives  to  the  infant  a  dis- 
tinctly marantic  appearance. 

Cases  of  cerebrospinal  meningitis  (Fig.  31)  frequently 
pass  into  a  state  of  extreme  emaciation  when  they  do  not 
succumb  in  the  acute  stage.  This  is  especially  true  of 
basilar  meningitis.  Of  course,  in  children  beyond  the  stage 
of  infancy  the  distinction  from  marasmus  need  not  be  made. 
In  fact,  if  one  bears  in  mind  the  history  of  the  case,  even  in 
the  very  young,  a  mistake  is  hardly  likely  to  occur,  and  the 
condition  is  mentioned  merely  to  make  the  list  of  possibili- 
ties complete. 


168  INFANTILE  ATROPHY. 

Finally  it  must  be  stated  that  malignant  disease  of  any 
form  affecting  the  young  will  be  recognized  by  the  pres- 
ence of  a  growth,  and  the  emphasis  of  local  symptoms  will 
direct  the  attention  to  the  seat  of  the  trouble. 

PROGNOSIS. 

Many  cases  of  marasmus  recover  completely,  no  vestige 
of  the  disease  remaining  in  after-life.  No  case  of  maras- 
mus should  be  regarded  as  hopeless  until  it  is  dead.  Many 
marvellous  transformations  are  wrought  if  the  proper  food 
can  be  quickly  found.  It  may  be  said  that  the  prognosis 
depends  entirely  upon  the  ease  and  facility  with  which  the 
practitioner  is  able  to  adjust  the  food  to  the  digestive 
capacity  and  to  the  nutritional  demands  of  the  individual. 
This  responsibility  is  not  always  discharged  without  diffi- 
culty. 

Favorable  signs  are:  a  speedy  change  in  the  stools 
for  the  better,  if  they  have  been  abnormal ;  a  small  but  ap- 
preciable gain  in  weight;  a  rise  in  temperature  to  normal 
or  to  a  few  tenths  of  a  degree  above  this  point.  Unfavor- 
able signs  are:  frequent  digestive  disturbances,  vomiting, 
diarrhea;  a  persistence  of  the  subnormal  temperature;  sta- 
tionary weight  or  a  loss  in  weight,  and  the  appearance  of 
edema  or  purpura.  Complications,  however  trivial,  espe- 
cially respiratory  or  infectious,  are  badly  borne.  Speaking 
generally,  it  can  be  stated  that  the  nearer  the  age  approaches 
a  year  and  the  shorter  the  duration  of  the  condition,  the 
better  is  the  prognosis.  Environmental  conditions  and 
attention  to  details  also  materially  influence  the  outcome  in 
individual  cases.  The  results  of  treatment  in  private  cases 
are  therefore  better  than  in  institutions. 


TREATMENT.  169 

TREATMENT. 

Preventive. — Disease  will  largely  disappear  when  pov- 
erty and  ignorance  are  no  more !  The  incidence  of  maras- 
mus will  share  in  this  general  decadence  of  misery  when 
society  ceases  to  rob  man  of  his  right  to  toil  and  to  share 
justly  in  the  products  of  his  labor,  and  no  longer  denies  to 
his  offspring  the  right  to  suck  its  mother's  breast.  So  too, 
when  physicians  and  mothers  cease  to  advance  their  arti- 
ficial and  false  ideas  as  to  the  feeding  of  infants,  and  dis- 
continue to  condemn  without  reason  the  human  milk- 
supply  in  individual  cases,  and  when  manufacturers  of 
patented  foods  cease  in  their  efforts  to  dictate  to  physicians 
how  to  feed  the  infants  of  the  land,  the  cases  of  marasmus 
will  disappear.  Baby-saving  shows,  mothers'  clubs,  neigh- 
borhood talks  by  competent  nurses  and  physicians,  and 
educational  propaganda  of  every  variety  should  be  en- 
couraged to  instruct  the  motherhood  of  the  country  as  to 
the  necessity  of  conserving  the  human  milk-supply,  and  as 
to  the  means  of  accomplishing  it.  Hospitalism  should  stop. 
The  moment  an  infant  has  recovered  from  an  acute  infec- 
tion, if  this  be  the  cause  of  its  presence  in  the  hospital,  it 
should  be  removed  therefrom  to  its  home  or  to  the  country, 
and  to  its  mother's  breast.  I  am  in  full  accord  with  the 
teachings  of  Henry  Dwight  Chapin  on  this  point.  If  pos- 
sible, during  its  stay  in  the  hospital  it  should  be  nursed  by 
its  mother.  When  for  a  sufficient  reason  an  infant  is  de- 
prived of  its  mother's  milk,  every  means  should  be  exerted 
to  provide  it  with  clean  cows'  milk  so  adapted  as  to  meet 
its  digestive  capabilities,  and  to  provide  it  with  sufficient 
calories  to  meet  its  nutritional  requirements. 

Active  Treatment. — Marasmus  should  not,  if  possible, 
be  treated  in  a  hospital.  From  the  preceding  it  may  be  cor- 


170  INFANTILE   ATROPHY. 

rectly  inferred  that  the  mortality  in  institutions  is  higher 
than  in  private  practice.  Especially  if  the  infant  be  under 
6  months  of  age,  every  effort  should  be  made  to  secure 
breast  feeding.  If  its  mother's  milk  is  not  available  the 
milk  of  another  woman  should  be  provided.  This  is  not 
always  possible,  however,  among  the  poor,  unless  a  volun- 
teer be  secured.  If  one  woman  does  not  supply  sufficient 
milk,  the  milk  of  many  healthy  women,  if  obtainable,  may 
be  mixed  together  and  fed  whole  or  diluted  by  dropper  or 
bottle.  If  all  breast-milk  feeding  cannot  be  had,  if  it  be  at 
all  possible,  one  or  more  feeds  of  human  milk  should  be 
given  in  twenty-four  hours.  A  case  recently  seen  with  Dr. 
J.  Cohen  illustrated  the  almost  specific  effect  of  breast  milk. 
The  marantic  infant,  4  months  of  age,  was  one  of  twins. 
The  patient  was  receiving  cows'  milk,  diluted,  and  the  other 
twin  was  upon  the  breast.  This  baby  was  fat  and  healthy ; 
the  other  was  in  a  dying  condition.  It  was  placed  upon  the 
breast  and  the  healthy  infant,  having  had  a  good  start,  was 
put  upon  carefully  adapted  cows'  milk.  The  sick  infant 
made  a  complete  and  brilliant  recovery  and  the  healthy  in- 
fant was  not  harmed  by  the  change.  Among  the  well-to-do, 
wet-nurses,  carefully  examined,  may  be  secured  at  various 
prices.  Their  services  are  often  invaluable  in  turning  the 
tide  toward  recovery.  Even  though  the  wet-nurse's  milk  is 
excellent,  it  must  be  stated  that  the  employment  of  these 
women  does  not  always  bring  peace  and  contentment  into 
the  home.  On  the  contrary,  the  practice  of  wet-nursing  is 
far  different  from  the  theory.  Temperamental  differences 
between  the  wet-nurse  and  the  mother,  together  with  house- 
hold and  domestic  problems,  often  bring  disaster  to  the 
arrangements  when  everything  seems  serene. 

Good  results,  too,  may  be  secured;  by  artificial  feeding. 


TREATMENT.  171 

Every  effort  should  be  made  to  study  thoroughly  the  pecul- 
iarities of  the  individual  infant,  and  to  determine  the  food 
element  or  elements  which  may  be  the  causative  factor  or 
factors.  The  essential  thing  is  to  individualize,  and  not  to 
treat  infants  by  the  same  routine  or  by  one  method  or  sys- 
tem of  feeding.  Another  essential  is  to  secure  clean  milk 
and  to  keep  it  clean.  With  this  in  view,  careful  attention 
should  be  given  to  nipples  and  bottles,  proper  refrigeration, 
amount  to  be  fed,  feeding  interval,  the  time  consumed  in 
taking  the  meal,  and  to  the  use  only  of  sterile  diluents.  As 
a  general  procedure  I  do  not  favor  the  recent  fad  of  long- 
interval  feeding,  for  the  reason  that  my  experience  with  the 
older  method  of  every  two  hours  up  to  3  months,  with 
from  one  to  two  feedings  during  the  night;  every  two  and 
one-half  hours  up  to  6  months,  and  one  or  no  feeding  dur- 
ing the  night ;  every  three  hours  up  to  9  months  and  every 
three  and  one-half  hours  after  this  time  has  demonstrated 
satisfactory  results  to  me.  I  see  no  reason  to  change  unless, 
in  individual  cases,  where  vomiting  might  be  benefited  by  a 
prolongation  of  the  interval.  During  the  day  an  infant 
should  be  fed  by  the  clock.  It  should  be  awakened  for  its 
food,  the  feeding  interval  being  counted  from  the  time  it 
started  its  meal,  not  from  the  time  at  which  it  finished  it. 
During  the  night  it  should  not  be  disturbed  at  all  for  food 
unless  it  be  very  weak.  The  meal  should  not  be  given 
hurriedly — at  least  from  fifteen  to  thirty  minutes  being  con- 
sumed, depending  upon  the  amount  fed.  The  nipple  should 
be  removed  from  the  mouth  at  the  end  of  every  third  or 
fourth  suck.  The  food  should  be  kept  warm  and  the  bottle 
should  be  held  for  the  baby,  and  it  should  not  be  permitted 
to  sleep  while  being  fed.  The  habit  of  regularity  will  soon 
be  formed,  and  the  little  patient  will  regularly  awaken  for 


172  INFANTILE   ATROPHY. 

its  meal.  The  quantity  fed  varies  as  the  appetite,  the  toler- 
ance, and  the  digestive  capacity.  Some  cases  do  well  on 
small  amounts  frequently  administered.  This  is  true  of 
cases  which  vomit,  especially  where  the  longer-interval 
feeding  fails.  Roughly,  the  quantity  may  be  regulated 
according  to  the  rules  given  in  Chapter  II,  page  102. 

It  is  well  to  calculate  the  caloric  value  of  the  daily  quan- 
tity of  food,  for  in  this  way  we  may  know  whether  we  are 
feeding  above  or  below  the  food  optimum.  Thus  may  we 
in  a  sense  prognosticate  as  to  whether  or  not  the  food  toler- 
ance permits  of  the  administration  of  sufficient  calories. 
Not  infrequently,  in  very  wasted  infants,  a  larger  number 
of  calories  are  required  to  secure  a  gain  in  weight  than  the 
somewhat  arbitrary  standard  would  indicate.  (See  Chap- 
ter II,  page  82.) 

Cases  which  exhibit  protein  intolerance  may  be  handled 
in  several  ways.  At  the  outset  I  wish  to  make  it  plain  that 
my  experience  does  not  permit  me  to  subscribe  to  the 
German  view,  that  unmodified  cows'  curd  is  not  only  never 
harmful,  but  can  be  fed  in  almost  incalculable  amounts.  I 
believe  that  mechanically  divided  cows'  curd,  or  curd  that 
has  previously  been  predigested  or,  both,  is  not  only  harm- 
less in  individual  cases,  but  of  great  value. 

The  coagulable  protein  may  be  entirely  eliminated  by 
the  use  of  whey.  With  this  method  I  have  had  little  experi- 
ence, and  therefore  can  neither  condemn  nor  praise  it.  It 
has  never  appealed  to  me,  although  some  authors  recom- 
mend its  use  and  report  very  good  results.  It  cannot  be 
continued  as  a  permanent  food,  as  it  is  lacking  in  con- 
structive elements.  As  soon  as  improvement  is  noted,  addi- 
tions of  cream,  from  */2  to  I  dram  at  a  time,  should  grad- 
ually be  made.  As  tolerance  is  noted  these  quantities  may 


TREATMENT.  173 

be  increased.  Instead  of  cream,  slowly  increasing  amounts 
of  whole  milk  may  be  added.  It  must  be  remembered  that 
cream  is  but  superfatted  milk,  and  that  whey  contains  some 
of  the  ferment  which  was  used  in  its  making.  There- 
fore, unless  the  whey  is  previously  heated  to  150°  F. 
to  kill  the  ferment,  either  the  cream  or  the  milk  will  become 
coagulated.  This  may  not  cause  any  inconvenience  as  far 
as  the  infant  is  concerned,  but  may  alarm  the  mother  or 
the  nurse,  or  the  curds  may  not  pass  readily  through  the 
nipple.  The  whey  must  not,  however,  be  heated  above  this 
or  the  lactalbumin  will  become  coagulated.  As  soon  as 
gain  is  inaugurated  or  it  is  seen  that  the  whcy-and-cream  or 
the  whey-and-milk  mixture  is  tolerated,  a  gradual  change 
should  be  made  to  dilutions  of  milk.  These  should  be  weak 
at  first  and  later  strengthened. 

In  selected  cases  I  have  had  success  with  Ramogen 
manufactured  by  Prof.  Biedert  (Chapter  III,  page  129).  It 
has  been  employed  as  a  temporary  food,  and  in  some  in- 
stances the  results  have  been  nothing  short  of  brilliant. 
This  is  likewise  true  of  Somatose  milk,  which  resembles 
Ramogen,  and  also  of  condensed  milk  in  selected  cases  of 
protein  and  fat  intolerance.  All  of  these  preparations,  how- 
ever, are  but  temporary  foods  and  must  be  safeguarded  by 
antirachitic  and  antiscorbutic  remedies  as  fruit-  and  animal- 
juices. 

The  character  o>f  the  coagulable  protein  may  be  changed 
by  simple  boiling  of  milk,  whole  or  diluted.  The  experi- 
mental work  of  Brennerman1  and  of  Ibrahim  seems  to 
prove  that  the  action  of  the  gastric  juice  upon  boiled  milk 
is  toi  cause  the  formation  of  curds  distinctly  softer  and  finer 
and  more  closely  resembling  those  of  human  milk  than  the 

1  Journal  A.  M.  A. 


174  INFANTILE   ATROPHY. 

curd  which  is  formed  as  the  result  of  the  action  of  the  gas- 
tric juice  upon  uncooked  milk.  In  most  cases,  however,  the 
simple  boiling  of  the  milk,  without  other  means  of  modifica- 
tion, in  cases  of  cow-curd  intolerance  is  insufficient  to  over- 
come the  difficulty.  In  any  case,  boiling  should  not  be  too 
long  continued  on  account  of  the  possibility  of  scurvy  or, 
if  it  must  be  continued  over  a  reasonable  length  of  time, 
fruit-juices  and  beef-juice  should  be  administered. 

The  addition  of  cereal-waters  or  gruels  made1  from 
arrowroot,  barley,  oatmeal,  rice,  or  wheat-flour,  plain,  as 
advocated  by  Jacobi  or  dextrinized  as  advocated  by  H.  D. 
Chapin,  is  an  excellent  means  of  causing  the  curd  to  become 
comminuted  in  the  stomach  and  to  materially  assist  in  its 
digestion.  Where  there  is  a  tendency  to  looseness  of  the 
bowels  arrowroot,  barley,  rice  or  wheat  may  be  used,  but 
where  costiveness  predominates  oatmeal  should  be  the 
choice.  If  starch  intolerance  exists,  as  manifested  by  much 
flatulence,  dextrinization  of  these  waters  or  gruels  may  be 
employed.  This  is  accomplished  by  the  addition  of  some 
preparation  of  malt  or  by  the  use  of  Cereo,  which  is  a 
glycerite  of  diastase  and  is  made  by  the  Cereo'  Company  of 
Tappan,  N.  Y.  This  Company  also  manufactures  a  fine 
grade  of  cereal  flours  from  which  these  waters  or  gruels 
may  be  made,  but  I  have  for  years  employed,  with  satisfac- 
tion the  simple  grains  (Chapter  II,  page  87).  In  cases  of 
difficult  protein  digestion  the  use  of  Keller's  Malt  Soup  is 
•said  to  give  brilliant  results,  especially  where  the  atrophy  is 
associated  with  an  intensely  antmoniacal  urine.  South- 
worth's  recent  experience  with  this  substance,  especially  in 
hospital  cases,  has  been  extremely  encouraging.  Malt  Soup 
closely  resembles  the  dextrinized  gruels  as  recommended  by 
Chapin.  Malt  Soup  preparations  made  in  America  by  the 


TREATMENT.  175 

Maltine  Company  are  now  available.  For  a  number  of 
years,  in  cases  where  starch  intolerance  appeared  con- 
spicuous, I  have  diluted  the  completed  cereal-water  with  50 
per  cent,  plain  boiled  water.  Where  I  have  wished  to 
impress  the  character  of  the  stools,  I  have  employed  these 
waters  full  strength  as  the  diluent,  entirely  excluding  plain 
water  from  the  formula. 

Sodium  citrate  will  promote  protein  tolerance  in  some 
cases,  especially  where  vomiting  is  present  (Chapter  II, 
page  109). 

Of  value  in  many  instances  is  pancreatization.  Other 
cases  do  not  do  so  well  upon  milk  or  milk  formulas  ordi- 
narily pancreatized.  Of  another  form  of  pancreatization 
and  curd  modification  that  has  given  me  much  satisfaction 
I  will  speak  presently.  The  feeding  of  pancreatized  for- 
mulas must  not  be  continued  too  long,  as  the  digestive  ap- 
paratus may  be  permanently  weakened.  The  food  is  sub- 
jected to  the  action  of  the  ferment  for  a  period  of  from 
twenty  to  thirty  minutes.  If  too  long  continued,  excessive 
formation  of  peptone  results  and  the  preparation  is  made 
bitter.  The  time  of  pancreatization  is  gradually  diminished 
and  finally  omitted  (Chapter  II,  page  108). 

In  treating  marasmus  proper  parental  intelligence  and 
co-operation  are  as  essential  as  proper  food  manipulation. 
The  necessary  means  to  purchase  the  best  milk  or  access  to 
a  free  milk  station  are  items  of  no  mean  importance.  Un- 
fortunately ignorance  and  poverty  often  prevail,  and  the 
physician  must  do  the  best  he  can  with  the  means  at  hand. 
Under  these  conditions  in  particular,  but  also,  among  the 
well-to-do,  where  protein  intolerance  was  present,  and  yet, 
where  I  felt  it  was  necessary  to  feed  protein  in  rather  large 
amounts,  I  have  had  most  happy  results  from  buttermilk 


176  INFANTILE   ATROPHY. 

mixtures.  It  requires  very  little  intelligence  for  the  mother 
to  learn  how  to  make  the  food.  Another  consideration  of 
prime  importance  is  its  cheapness.  My  method  of  using 
this  preparation  is  as  follows:  I  first  place  the  baby  upon 
the  buttermilk-and-flour  mixture  (Chapter  III,  page  123), 
omitting  the  sugar  until  the  movements  become  normal. 
This  is  practically  an  eiweissmilch  with  the  exception  that 
it  lacks  the  curd  of  an  extra  litre  of  milk  and  it  contains 
flour.  I  now  commence  to  add  cane-sugar,  running  the 
amount  up  to  fifteen  and  three-fourths  teaspoonfuls  to  the 
two-quart  mixture.  If  everything  goes  well,  and  usually 
the  gain  in  weight  is  inaugurated  after  the  addition  of  the 
sugar,  I  gradually  add  cream,  first  a  half-dram  to  every 
other  bottle,  then  to  every  bottle,  and  gradually  increase 
the  amount  as  long  as  tolerance  is  maintained.  I  am  forced, 
from  my  results,  to  regard  buttermilk  feeding  as  an  ex- 
ceptionally valuable  dietetic  measure  in  marasmus.  I  have 
learned  to  depend  upon  it,  as  in  many  instances  I  am  sure 
that  it  has  saved  lives.  The  mixture  is,  as  before  stated, 
easily  made,  but  directions  must  be  carefully  followed. 
This  is  particularly  true  with  reference  to  the  constant 
stirring  of  the  mixture  during  the  second  boiling  (if  it  is 
employed  in  this  manner,  which  I  believe  gives  better  re- 
sults than  when  the  second  boiling  is  omitted),  i.e.,  after 
the  buttermilk  and  flour  and  sugar  solutions  or  the  flour 
solution  alone  have  been  mixed  together.  Unless  it  is 
thoroughly  stirred  from  the  minute  it  is  placed  upon  a  low 
fire,  unmanageable  lumping  will  ensue.  An  infant  may  be 
kept  on  buttermilk  for  months  provided  antiscorbutic  reme- 
dies, as  beef-juice  and  vegetable  broth  or  fruit-juices,  are 
administered  at  suitable  intervals.  In  conjunction  codliver 
oil  is  valuable,  especially  when  adminstered  by  inunction. 


TREATMENT.  177 

As  soon  as  a  substantial  gain  is  recorded  (3  to  5  pounds) 
gradual  or  instantaneous  transference  may  be  made  to 
properly  adapted  formulas  of  whole  milk.  I  cannot  recom- 
mend this  substance  too  highly  if  it  be  intelligently 
employed. 

Instead  of  buttermilk  and  flour  without  sugar,  eiweiss- 
milch answers  an  admirable  purpose  in  causing  the  stools 
to  become  constipated  and  normal  in  aspect.  Gradually 
carbohydrate,  in  the  form  of  cane-sugar  or  Dextri-Maltose, 
is  added.  After  five  to  six  weeks  a  prompt  return  is  made 
to  whole-milk  dilutions.  Eiweissmilch  may  not  be  con- 
venient and  may  be  difficult  to  make.  The  dried  prepara- 
tion of  eiweissmilch  on  the  market  known  as  Larosan  is 
extensively  employed  by  Finkelstein  himself,  and  gives 
good  results.  Personally  I  have  had  a  limited  experience 
with  it.  I  have  observed  its  use  in  Finkelstein's  clinic  in 
Berlin.  There  I  witnessed  some  good  effects  in  the  exuda- 
tive diathesis  (vide  Chapter  XI,  page  309)  and  in  maras- 
mus. The  stools  in  diarrhea  in  which  sugar  is  the  active 
etiologic  factor  are  also  favorably  influenced. 

Asked  to  name  one  method  of  treating  marasmus, 
where  either  protein  or  fat  or  both  have  given,  trouble, 
which  I  favor  most  or  rather  which  has  given  me  the  best 
results,  aside  from  buttermilk,  I  should  unhesitatingly 
recommend  the  use  of  some  simple  milk  formula  ivherein 
the  curd  had  been  modified  by  the  old- fashioned  Hour  ball, 
with  or  without  the  addition  of  pancreatin,  or  by  the  use 
of  Benger's  Food,  which  is  flour  ball  containing  pancreatin. 
While  this  is  a  proprietary  its;  composition  is  clearly  stated, 
and  it  is  recommended  as  a  milk  modifier  and  not  as  a  food. 
It  simply  represents  an  easy  way  of  using  flour  ball  without 
having  to  go  to  the  trouble  of  making  it.  Either  one  of 

12 


178  INFANTILE   ATROPHY. 

these  preparations  may  be  added  in  the  amount  of  from 
2.y2  to  5  per  cent,  of  the  total  quantity  of  the  formula.  I 
find  the  former  percentage  to  answer  most  purposes.  The 
heating  to  which  the  milk  is  subjected  also  materially 
assists  in  the  digestion  of  the  curd.  I  have  never  seen  a 
case  of  scurvy  develop  oin  account  of  the  heating  except  in 
one  instance  where  an  unruly  infant  (Plate  XI)  refused 
to  take  fruit-  or  animal-  juices.  I  believe  this  to  be 
due  to  the  fact  that  it  has  not  been  continued  over  too 
long  a  period  and  because  fruit- juices,  vegetable  broth, 
and  meat- juice  are  always  used  in  conjunction  with  the 
milk  feeding — one  of  them  or  all.  The  method)  of  using 
flour  ball  or  Benger's  Food  is  described  in  Chapter  III.  The 
effect  of  both  of  these  preparations  upon  the  stools  is  rapid. 
The  latter  are  changed  within  twenty-four  to  forty-eight 
hours  into  a  light  or  golden-yellow  mass  of  smooth,  mushy 
consistency,  with  the  characteristic  slightly  acid,  not  un- 
pleasant odor  of  normal  breast-milk  stools.  This  effect  is 
continuous.  Vomiting  is  usually  checked,  although  it  may 
continue  and  be  without  serious  significance,  and  a  gain  in 
weight  is  inaugurated.  Both  the  Benger's  Food  and  the 
flour  ball,  as  soon  as  the  indications  permit,  are  gradually 
reduced  and  finally  omitted.  The  heating,  however,  is  con- 
tinued for  a  week  or  so  and  then  stopped. 

The  quantity  and  quality  of  the  formula  are  increased  as 
the  appetite  and  digestive  processes  warrant.  If  constipation 
persists  it  may  be  materially  lessened  by  the  use  of  from 
10  to  40  drops  of  Philip's  Milk  of  Magnesia  in  each  bottle, 
or  in  every  other  bottle,  or  but  once  daily  according  to  the 
result  obtained.  Of  late  I  have  been  favorably  impressed 
by  the  use  of  the  liquid  paraffin  preparations  (Chapter  VIII, 
page  254). 


TREATMENT.  179 

As  to  the  character  of  the  formula  itself,  experience  and 
personal  equation  count  for  much.  This  statement  is  not 
made  to  sidestep  the  issue  or  on  account  of  a  desire  to  deny 
to  the  practitioner  a  clear  exposition  of  the  details  of  for- 
mula manipulation,  but  simply  because  it  is  a  fact  learned 
from  large  experience.  It  must,  however,  be  stated  as  a 
truism  that  as  good  results  may  be  obtained  by  the  simple 
dilution  of  whole  milkt  or  of  skimmed  milk  as  with  any 
other  method.  One  should  start  with  a  strength  of  about 
one-fourth  milk  and  three-fourths  diluent  and  gradually  in- 
crease the  quantity  of  milk.  The  key  to  the  entire  situation 
is  provided  by  a  careful  study  of  the  stools,  and  the  adapta- 
tion of  the  strength  of  the  formula  to  the  digestive  capacity. 
The  method  of  dilution  or  of  modification  is  really  a  matter 
of  secondary  importance.  The  physician  must  simply  be 
able  to  increase  or  diminish  the  coagulable  protein  or  any 
other  of  the  food  elements  according  to  the  indication.  It 
cannot  be  too  strongly  emphasized  that  success  depends 
upon  the  ability  to  individualize. 

If  the  cause  of  the  digestive  disturbance  be  fat  intoler- 
ance (Chapter  II,  page  no),  whey  may  be  employed  for  a 
short  time.  It  contains  a  little  less  than  I  per  cent,  of  fat. 
To  it  may  be  added  gradually  increasing  amounts  of 
skimmed  milk. 

In  other  instances  signal  success  has  been  achieved 
by  the  use  of  diluted  whole  milk  or  diluted  skimmed  milk. 
In  all  cases  where  skimmed  milk  is  employed,  it  should  be 
obtained  by  skimming  the  best  obtainable  whole  milk,  at 
home,  after  the  cream  is  permitted  to  thoroughly  rise.  As 
tolerance  is  established  one-fourth,  one-half,  and  then 
three-fourths  of  the  cream,  which  has  been  removed,  may 
be  poured  back  into  the  jar  and  the  whole  well  shaken  and 


180  INFANTILE   ATROPHY. 

then  diluted  to  any  strength,  or  any  of  these  preparations 
may  be  pancreatized  or  modified  by  flour  ball  and  pancreatin 
or  by  Benger's  Food.  The  pancreatin  in  each  instances  acts 
upon  the  fat  by  reason  of  the  steapsin  which  it  contains.  In 
using  pancreatin  only  the  best  possible  product  should  be 
employed  and  pains  should  be  taken  to  see  that  it  is  strictly 
fresh.  That  manufactured  by  Fairchild  Bros,  and  Foster 
has  given  me  satisfaction.  Buttermilk  with  flour  and  sugar 
or  eiweissmilch  with  additional  carbohydrates  are  also 
exceptionally  valuable  in  cases  of  fat  intolerance,  especially 
the  former,  since  both  are  weak  in  fat. 

If  cane-sugar  be  employed  to  supply  the  extra  carbo- 
hydrate, rarely  will  any  disturbance  attributable  to>  this 
source  be  demonstrable.  Jacobi  for  years  has  advocated 
the  use  of  this  chemical  in  preference  to  milk-sugar,  and 
my  experience  bears  out  the  validity  of  his  teachings.  Of 
late,  the  malt-sugar  preparations  have  come  into1  prominence 
by  reason  of  the  impetus  given  them  by  the  German  school 
of  pediatrists.  They  owe  their  popularity  to<  the  fact  that 
they  often  cause  a  rapid  and  permanent  increase  in  weight 
because  maltose,  which  they  are  all  said  to  contain  in  about 
the  proportion  of  50  per  cent.,  is  readily  absorbed  and  rapidly 
assimilated  by  the  tissues.  The  muscle  and  body  juices 
contain  a  maltose-splitting  ferment,  and  therefore  any  mal- 
tose absorbed  as  such  is  converted  after  it  leaves  the  intes- 
tinal canal  and  is  not  again  eliminated  as  maltose.  On  the 
other  hand,  lactose  and  saccharose,  when  fed  in  excessive 
amounts,  are  eliminated  in  the  urine,  not  being  converted  in 
the  tissues.  Maltose  is  said  to  be  twice  as  assimilable  as 
either  of  these  two.  Mead- Johnson's  Dextri-Maltose, 
Loeflund's  Food  Maltose,  and  Soxhlet's  Nahrzucker  are 
practically  identical  in  composition.  The  first  is  more  avail- 


TREATMENT.  181 

able  on  account  of  its  comparative  cheapness.  These  prep- 
arations are  used  in  the  same  strength  as  either  lactose  or 
saccharose,  being  added  in  the  strength  of  from  i  to  5  per 
cent. 

If  sugar  is  not  borne  well  at  all,  buttermilk  plain,  or 
buttermilk  with  flour,  but  without  sugar,  or  eiweissmilch 
furnishes  the  means  of  giving  nutriment  with  a  minimum  of 
this  substance.  Additional  sweetness  may  be  secured  by 
adding  i  grain  of  saccharin  to  the  quart.  Gradually,  extra 
carbohydrate  is  added.  Cases  which  do  not  tolerate  sugar 
well  suffer  especially  from  a  subnormal  temperature  when 
deprived  of  this  element,  and  therefore  must  receive  extra 
care  by  being  protected  with  proper  clothing  and  external 
heat. 

Where  the  history  provides  the  evidences  of  starch 
injury,  I.  A.  Abt2  recommends  milk  containing  a  moderate 
amount  of  fat  and  the  withdrawal  of  carbohydrate  food, 
especially  buttermilk  mixtures,  malt-soup,  and  cereal  de- 
coctions. If  possible  to  secure  it,  breast  milk  offers 
the  greatest  chance  for  recovery.  It  is  administered  first 
in  small  quantities.  The  primary  withdrawal  of  starch 
may,  especially  in  the  hydremic  types,  cause  an  initial  loss 
in  weight.  Next  to  breast  milk  undiluted  cows'  milk,  at 
first  in  small  and  then  in  gradually  increasing  amounts,  is 
recommended.  Tea  or  water  sweetened  with  saccharin 
(gr.  j  to  the  quart)  may  be  administered  to  supply  fluid. 
Care  should  be  taken  not  to  exceed  the  infant's  tolerance 
for  fats  or,  in  fact,  protein  and  sugar  as  well,  as  it  must 
be  remembered  that  the  injury  produced  by  the  prolonged 
feeding  of  starch  has  impaired  the  tolerance  for  all  the  food 
elements. 


2  Journal  A.  M.  A.,  October  4,  1913,  p.  1276. 


182  INFANTILE   ATROPHY. 

Food  Preparations  Other  Than  Milk. — Useful  in  the 
treatment  of  marasmus  are  beef -juice,  freshly  made  as 
directed  on  page  145,  Chapter  III,  or  Valentine's  meat-juice, 
fruit-juices — from  oranges,  grapes,  or  prunes  stewed  with- 
out sugar.  Vegetable  broths  and  olive  oil  are  also  useful. 

Meat-juices  or  fruit-juices  are  best  administered,  in  small 
amounts,  exactly  one-half  hour  before  feeding  time.  This 
permits  the  juice  to  enter  the  stomach  after  it  is  empty. 
The  previous  meal  has,  under  normal  conditions,  practically 
passed  out  and  entered  the  duodenum;  hence  there  is  no 
admixture  of  meat  and  milk — a  scientific  adaptation  of  the 
Mosaic  law  which  finds  modern  verification  for  its  originally 
physical,  though  Biblical,  basis. 

Vegetable  broth  (Chapter  III,  page  146)  is  used  as  a 
drink.  It  is  usually  acceptable  to  the  infant.  Sometimes  it 
is  not.  It  is  a  valuable  antiscorbutic,  antirachitic,  antiexu- 
dative,  antacid,  and  laxative  remedy.  Its  use,  however, 
should  not  be  forced.  In  fact,  this  is  true  of  any  remedy  or 
any  food. 

Olive  oil  in  doses  of  ^  to  i  fluidram  is  sometimes!  well 
tolerated  where  the  fat  of  cows'  milk  cannot  be  digested. 
It  is  best  given  one-half  hour  after  feeding,  especially 
where  skimmed-milk  preparations  are  used  as  food. 

Rectal  alimentation  with  small  amounts  of  pancreatized 
milk,  and  whisky  nix  to  m.xx,  administered  once  or  twice 
in  twenty-four  hours  high  into  the  bowel,  and  previously 
wanned  and  following  a  cleansing1  enema,  may  be  useful  in 
cases  of  extreme  asthenia  as  a  life-saving  agent. 

Hypodermoclysis  with  normal  saline  solution,  properly 
warmed  and  administered  in  amounts  varying  from  2  to  5 
ounces  and  under  strictly  aseptic  conditions,  and  not  oftener 
than  once  in  twenty-four  hours,  is  a  useful  remedy  (Chap- 


DRUG   THERAPY.  183 

ter  XIII).  This  is  especially  so  in  those  cases  of  atrophy 
which  have  followed  an  attack  of  summer  diarrhea  (milk 
intoxication)  and  in  which  the  onset  has  been  rather  abrupt. 
The  tissues  have  been  speedily  dehydrated  and  demineralized 
by  the  tremendous  loss  of  water  per  rectum. 

HYGIENIC  MANAGEMENT. 

These  babies  do  better  in  a  warm  atmosphere  of  pure 
air.  As  before  stated,  they  should  not  be  kept  in  hospitals. 
If  orphans  are  deserted,  they  should  be  placed  in  homes,  if 
possible,  especially  if  the  caretaker  can  at  the  same  time  give 
them  the  breast.  The  municipality  should  thus  provide 
home  shelter  wherever  possible  for  its  infant  charges  rather 
than  maintain  them  in  almshouses. 

Regularity  in  feeding,  feeding  proper  quantities,  neither 
too  fast  nor  too  slow,  proper  warming  of  the  bottle  and 
attention  to  the  minutest  detail,  which  may  be  included  in 
the  expression  "intelligent  and  wholesome  care,"  should  be 
provided. 

DRUG  THERAPY. 

Drugs  occupy  a  position  decidedly  subordinate  to  the 
dietetic  and  hygienic  management  of  these  cases.  There 
are  no  specifics.  Extract  of  thyroid  has  been  recommended 
as  well  as  extract  of  thymus.  I  have  had  little  experience 
with  the  former  and  none  with  the  latter.  Thyroid,  in  my 
hands,  has  given  no  indication  of  its  usefulness.  On  the 
other  hand,  Henry  Heiman,  in  a  personal  communication, 
recommends  its  use  empirically  in  certain  cases  which  can- 
not be  classified.  He  administers  it  in  the  dose  of  from  y2 
to  i  grain  three  times  a  day.  It  is  my  belief  that  the  physi- 
cian who  leans  upon  any  drug  therapy  in  this  condition,  to 


184  INFANTILE  ATROPHY. 

the  exclusion  of  the  application  of  his  knowledge  of  dietetic 
detail-  and  individualization,  will  have  poor  results.  Tinc- 
ture of  nux  vomica  in  mj  to  mij  doses  t  i.  d.,  a,  c.,  may  be 
useful  to  increase  the  appetite  and  the  motor  function  of  the 
gastrointestinal  tract.  Extract  of  pancreatin  and  taka- 
diastase,  alone  or  in  combination,  and  rubbed  up  with  5 
grains  of  white  sugar  may  assist  in  protein  and  fat  diges- 
tion. Paraf  JavaTs  solution  of  strontium,  bromid  may  re- 
lieve colic,  vomiting,  and  flatulency.  A  peaceful  night  may 
be  secured  by  a  single  or  double  dose  of 

•3?!  -1    •    !  ' 

Ifc  Sodii  bromidi   gr.  ij. 

Tr.  opii  camph.,  TH.ij. 

Syr.  simpl., 

Aquae  menthae  pip.,  or 

Aquae  camph.,  or 

Aquae  anisi  aa  q.  s.  ad  fSj. 

A  few  drops  of  HC1  dil.  niiij-v  may  assist  in  the  diges- 
tion of  curd  and  prevent  fermentation.  An  initial  dose  of 
castor  oil  and  spiced  syrup  of  rhubarb,  equal  parts,  will 
cleanse  the  bowels,  relieve  fermentative  diarrhea,  and  is 
often  of  service.  Later  it  may  be  followed  by  small  doses 
of  aromatic  cascara  for  its  tonic  effect.  Constipation  may 
further  be  relieved  by  suppositories,  enemas  of  olive  oil  or 
glycerin-and-soap  water,  and  by  the  use  of  liquid  paraffin 
preparations  as  before  stated.  Likewise  it  may  be  repeated 
that  codliver  oil,  by  inunction,  is  a  valuable  agent. 


CHAPTER  V. 
RICKETS. 

Synonyms. — Rachitis,  English  Disease. 

Definition. —  Rickets  is  a  general  disease  occurring  as 
the  result  of  a  perverted  metabolism,  the  exact  nature  of 
which  is  not  at  present  entirely  understood.  It  manifests 
itself  clinically  by  changes  in  the  osseous,  muscular,  nerv- 
ous, and  digestive  systems. 

PATHOLOGY. 

While  rickets  depends  upon  some  form  of  toxemia  or 
metabolic  disturbance  which  involves  primarily  the  nervous, 
digestive,  muscular,  and  osseous  systems,  the  lesions  char- 
acteristic of  the  disease  are  found  only  in  the  bones. 
Whether  these  changes  are  inflammatory  or  not  is  still  a 
matter  for  discussion.  The  most  marked  changes  are  in 
the  long  bones  and  occur  in  the  bone-forming  centers,  i.e., 
in  the  cartilage  between  the  shaft  and  the  epiphysis,  and  in 
the  bone-forming  or  inner  layer  of  the  periosteum,  and  in 
the  inner  layers  of  bone  which  lie  next  to  the  medullary 
canal.  In  all  these  situations  except  in  the  neighborhood  of 
the  medullary  canal,  in  health  there  occurs  proliferation  of 
cells  which  are  later  replaced  by  bone.  This  is  accomplished 
by  the  deposition  of  inorganic  substances.  In  this  way  the 
long  bones  grow  in  length  and  in  thickness.  The  medullary 
canal  is  widened  by  the  absorption  of  the  layers  of  bone 
found  in  this  situation. 

In  rickets  there  occurs  increased  activity  in  the  prolif- 
eration of  cells  in  the  hyaline  cartilage  between  the  epiph- 

(185) 


186  RICKETS. 

ysis  and  the  shaft  and  in  the  inner  layer  of  the  periosteum. 
There  also  occurs  absorption  in  the  medullary  region,  but 
decidedly  less  rapidly  than  in  health.  In  addition  there  is 
an  intense  increase  in  the  vascularization  of  the  parts  and 
there  is  a  diminution  in  the  deposition  of  inorganic  matter, 
i.e.,  the  quantity  of  organic  matter  far  exceeds  the  inorganic. 
Thus  the  process  occurring  in  health  is  reversed.  The 
medullary  canal  becomes  filled  with  rapidly  proliferating 
cells  that  resemble  granulation  tissue.  It  can  be  seen,  there- 
fore, that  as  a  result  of  this  increase  in  cell  proliferation  and 
in  the  lack  of  inorganic  matter  the  epiphyses  will  become 
enlarged  and  thickened.  Also  the  surface  of  the  long 
bones  will  become  irregular  and  the  bones  will  readily 
yield  to  the  effects  of  muscular  traction,  gravity,  and  atmos- 
pheric pressure.  These  bones  also  readily  bend  or,  if  frac- 
ture occurs^  it  will  not  be  complete,  but  will  be  of  the 
"green  stick"  variety. 

The  same  process  of  cell  proliferation  and  of  increased 
vascularization,  together  with  a  scarcity  of  mineral  con- 
stituents, takes  place  in  the  centers  of  ossification  of  the 
flat  bones.  This  is  especially  true  of  the  cranial  bones. 
This  gives  rise  to  the  formation  of  areas  of  thickness,  or 
bosses.  In  those  areas  where  the  formation  of  bosses  is 
absent,  absolute  or  relative  thinning  of  the  bone  results  in 
craniotabes. 

The  rachitic  processes  may  become  arrested  at  any  time 
and  complete  absorption  with  perfect  restoration  to  the  nor- 
mal will  occur.  In  fact  it  may  be  impossible  to  recognize 
that  the  present  adult  was  a  rachitic  infant.  The  deposition 
of  inorganic  substances  may  proceed  to  such  a  degree  as  to 
cause  the  bone  to  become  unusually  hard  or  ivorylike 
(ebonization). 


ETIOLOGY.  187 

ETIOLOGY. 

This  disease  is  confined  almost  exclusively  to  infants 
who  are  artificially  fed.  When  it  occurs  in  the  breast-fed 
it  does  not  appear  until  late  in  infancy.  Its  incidence  in 
these  babies  is  evident  beyond  the  first  year,  i.e.,  in  infants 
who  have  been  kept  upon  the  breast  too  long  and  who  are 
therefore  receiving  food  deficient  usually  in  the  elements 
which  are  essential  to  a  vigorous  metabolism.  Just  what 
exists  in  breast  milk  that  prevents,  and  what  is  absent  or 
present  in  cows'  milk  which  permits  or  causes  the  symp- 
toms of  rickets  to  appear,  has  not  been  clearly  defined.  It 
may  be  that  the  frequent  disturbances  of  digestion  to  which 
artificially  reared  babies  are  prone,  give  rise  to  the  develop- 
ment of  enteric  fermentation  and  the  subsequent  formation 
of  toxins  which,  circulating  in  the  blood,  exert  their  dele- 
terious effects  upon  metabolism  and  nutrition,  preventing 
the  normal  development  of  nervous,  muscular,  and  osseous 
tissue.  Certain  it  is  that  clinical  experience  emphasizes  the 
frequent  occurrence  of  rickets  in  individuals  who  receive  a 
deficiency  of  fat  and  protein  either  by  accident  or  through 
intention,  the  latter  necessitated  by  the  fact  that  the  digest- 
ive powers  are  deficient  in  their  ability  to  take  care  of  these 
substances.  Thus,  where  mixtures  low  in  fat  or  low  in 
protein  are  fed  over  a  long  period1  of  time,  rickets  is  likely 
to  develop.  Therefore  infants  who  are  continuously  fed 
upon  condensed  milk,  which  is  notoriously  deficient  in  these 
substances  and  in  mineral  constituents  as  well,  containing 
at  the  same  time  an  excessive  amount  of  carbohydrate 
(sugar),  are  frequently  victims  of  this  disease.  Without 
protein  and  fat,  normal  development  of  bone,  muscle,  and 
nervous  tissues  cannot  occur.  In  rickets  these  are  uni- 
formly affected  and  exhibit  a  physical  weakness  and  irri- 


188  RICKETS. 

tability  that  cannot  be  readily  accounted  for  in  any  other 
way. 

Fat  and  protein  deficiency  may  occur  not  only,  as  just 
stated,  as  the  result  of  a  food  mixture  weak  in  these  sub- 
stances, but  may  supervene  as  well  where  the  formula  for 
some  reason  disagrees  and  at  the  same  time  contains  not 
only  a  sufficiency  of  the  food  elements,  but  an  excess.  In 
the  first  instance  they  may  be  deficient  for  the  individual. 
The  personal  equation  therefore  or  the  individual's  idio- 
syncrasy must  be  considered  in  coming"  to*  a  correct  con- 
clusion. In  the  latter  instance  the  deficiency  depends  upon 
some  digestive  disturbance  due  to  the  excess  per  se,  or  upon 
intolerance  of  some  other  element,  notably  carbohydrate. 
In  either  instance  the  resultant  is  malassimilation — an 
amount  of  fat  or  protein  deficient  for  the  individual's 
proper  metabolism,  being  absorbed. 

A  deficiency  of  lime  salts  in  the  diet  could  readily 
account  for  the  state  of  hyperirritability  of  the  nervous 
system  in  rickety  infants  who  are  so  eminently  liable  to 
convulsion.  Lime  is  a  nerve  sedative.  The  salts  of  sodium 
and  potassium  are  responsible  frequently  for  nervous  ex- 
citability. Therefore  any  food  lacking  a  sufficient  amount 
of  calcium  may  predispose  to  this  disease.  The  deficiency 
of  lime  in  the  tissues,  theoretically  at  least,  may  be  produced 
as  in  the  case  of  fat  and  protein,  by  its  absence  or  deficiency 
in  the  food,  or  by  the  failure  of  the  organism  to  assimilate 
it  sufficiently,  or  by  its  increased  elimination  from  the  body. 
The  last  depends  upon  the  ease  with  which  it  could  combine 
with  the  active  agent,  presuming  this  to  be  an  acid,  respon- 
sible for  the  disease;  or  it  may  be  due)  to  the  untoward 
influence  of  diseased  or  functionally  perverted  parathyroids 
upon  the  maintenance  of  a  proper  calcium  balance. 


ETIOLOGY.  189 

The  frequent  association  of  rickets!  with  tuberculosis  or, 
rather,  the  common  occurrence  of  tubercular  lesions  in 
rachitic  children,  is  an  ordinary  clinical  experience  that  re- 
quires no  special  emphasis.  However,  the  degree  of  inter- 
dependence of  these  two  diseases  is  not  clear  except  in  so 
far  as  it  is  a  matter  of  common  knowledge  that  all  infec- 
tions are  not  only  more  likely  to  occur  in  the  rachitic,  but 
that  they  are  marked  by  greater  severity.  Consequently, 
under  these  circumstances,  these  diseases  offer  a  graver 
prognosis.  In  a  word,  the  resistance  is  lowered  in  rickets 
and  it  is  readily  understood  that  the  vitality  may  speedily 
be  vitiated  by  a  deficiency,  especially  of  protein  and  of  fat 
as  well. 

A  factor  of  prime  importance  in  its  bearing  upon  the 
development  of  rickets  is  provided  by  faulty  hygiene. 
Overcrowding,  improper  clothing,  deficient  aeration  and 
sunshine  are  peculiarly  common  to  those  in  whom  this  dis- 
ease appears  with  the  greatest  frequency.  It  may  be  that 
the  frequent  association  of  rickets  and  of  tuberculosis  finds 
its  origin  in  the  single  etiologic  factor)  of  faulty  hygiene, 
and  this  symbiosis,  as  it  were,  may  represent  nothing  more 
than  a  coincidence  in  that  the  same  factor  provides  a  com- 
fortable habitat  for  the  exciting  cause  of  each. 

Race  has  its  influence  too.  The  disease  in  America  is 
met  decidedly  most  often  in  the  Negro  and  next  in  the 
Italian  immigrant.  The  filth  and  poor  rearing  of  the  former, 
and  both  these  factors  together  with  the  excessively  starchy 
diet  of  the  latter,  evidently  provide  sufficient  reasons  for  the 
development  of  this  disease.  From  this,  however,  it  cannot 
be  concluded  that  the  rich  are  immune  to  rickets,  although 
its  incidence  is  decidedly  less  where  material  assets  are  suffi- 
cient to  provide  for  the  ordinary  and  the  extraordinary 
requirements  of  existence. 


190  RICKETS. 

Sex  has  no  bearing  on  the  frequency  of  rickets  and 
heredity  is  without  influence.  The  occurrence  of  several 
subsequent  cases  of  this  disease  in  all  or  in  a  part  of  the 
children  of  one  family  can  be  explained  by  the  continuous 
presence  of  the  same  predisposing  and  exciting  factors. 

As  to  age,  it  must  be  stated  that  we  are  dealing  here  with 
rickets  as  we  commonly  see  it  in  practice,  and  not  with 
those  questionable  types  of  the  disease  (achondroplasia, 
fetal  rickets)  which  depend  upon  some  obscure  uterine 
influence.  Nor  do  I  intend  to  dwell  upon  the  rickets  of 
puberty,  but  to  confine  the  description  to  a  consideration  of 
the  disease  as  it  is  met  in  infancy  and  in  childhood.  It  is 
rare  in  very  early  infancy.  It  may  appear  at  3  months. 
It  is  more  likely  to  occur  after  6  months  and  to  manifest 
itself  more  frankly  after  I  year  of  age.  It  is  important  to 
remember  that  the  initial  symptoms  of  the  disease,  to'  which 
reference  will  again  be  made,  frequently  appear  quite  early. 
These  symptoms  are  mild  at  first  and  are  therefore  fre- 
quently unrecognized.  My  purpose  in  emphasizing  this 
fact  depends  upon  a  desire  to  insist  upon  our  ability  to  abort 
the  further  development  of  this  disease.  If  the  proper 
hygienic  and  dietetic  measures  are  inaugurated  as  soon  as 
the  significance  of  these  initial  features  are  recognized  and 
appreciated,  this  statement  becomes  a  truism,.  If  the  infant 
escapes,  it  is  rarely  possible  that  the  condition  will  begin  in 
childhood,  i.e.,  after  2  years. 

Among  predisposing  factors  of  important  moment,  in 
fact  regarded  by  some  authors  as  sufficiently  influential  to 
be  included  among  the  most  important  exciting  causes,  is  a 
deficiency  of  sunshine,  fresh  air,  and  the  presence  of  damp 
surroundings, — in  a  word,  as  before  stated,  a  vicious 
hygienic  environment.  While  it  is  true  that  the  whole 


SYMPTOMS.  191 

economy  is  depressed  and  vitiated  by  such  influences  and 
therefore  predisposed  to  any  disease,  infectious  or  other- 
wise, we  cannot  help  but  recognize  the  presence  of  some 
other  factor  as  the  active  agent.  All  children  subjected  to 
such  influences  do  not  develop  rickets  and  many  acquire  the 
disease  who  are  not  so  surrounded.  While  the  disease 
occurs  with  greater  frequency  among  the  poor,  it  is  also 
found  quite  commonly  among  the  rich,  and  in  the  former 
instance  its  more  frequent  incidence  is  perhaps  relative. 
Rickets  is  undoubtedly  a  disease  of  metabolism  and  diet. 
All  other  etiologic  influences  are  predisposing  and  not  active. 

SYMPTOMS. 

The  most  apparent  symptoms  of  a  well-developed  case 
of  this  affection  are  referred  to  the  osseous  system.  If,  how- 
ever, careful  investigation  be  made,  certain  other  features 
may  be  detected  early  and  protective  measures  be  instituted 
to  prevent  the  further  development  of  the  disease.  This 
statement  needs  qualification,  as  it  is  possible  that  the 
process  may  be  spontaneously  arrested  at  any  time.  It  is 
not  always  safe  therefore  to  conclude  that  the  cessation  of 
symptoms  depends  upon  any  therapeutic  or  dietetic  meas- 
ures which  have  been  instituted.  Nevertheless  it  is  a  clinical 
fact  readily  demonstrable  by  extended  experience  that,  if 
certain  precautionary  measures,  which  will  be  pointed  out 
later,  are  thrown  about  individual  cases  of  artificial  feeding, 
rickets  need  not  and  does  not  develop. 

Among  the  earliest  evidences  of  a  rachitic  tendency, 
headsweating  occurs  with  much  frequency.  It  is  not 
pathognomonic  in  itself,  as  it  may  occur  in  healthy  babies, 
but  when  associated  with  other  conditions  is  eminently 
suggestive.  The  sweating  may  be  confined  to  the  forehead 


192  RICKETS. 

or  it  may  involve  the  occipital  portions  as  well.  It  com- 
monly occurs  during  the  act  of  nursing  and  especially  dur- 
ing sleep.  It  may  be  so  profuse  as  to  cause  a  corona  of 
dampness  to  surround  the  spot  where  the  head  comes 
in  contact  with  the  pillow.  Seasonal  influences  have  no 
bearing  upon  its  presence.  It  is  continued  well  into 
childhood  and  may,  in  conjunction  with  draughts  and  sud- 
den exposures,  be  responsible  for  some  of  the  congestive  and 
infectious  accompaniments  or  sequences  of  the  disease 
(colds,  pneumonia,  bronchitis,  etc.). 

Craniotabes,  or  the  thinning  of  the  skull  in  spots,  ap- 
pears in  some  instances  as  early  as  the  third  month  and  is 
said,  in  a  so-called  congenital  form,  to  even  precede  this 
age.  Of  this  variety  of  rickets  I  have  met  but  few  instances. 
Craniotabes  may  affect  the  parietal  and  frontal  bones,  but 
more  commonly  involves  the  perpendicular  portion  of  the 
occiput.  This  is  often  flattened  by  the  pressure  of  the  head 
upon  the  pillow,  and  over  the  flattened  area  the  hair  is 
commonly  worn  away.  This  flatness  must  be  distinguished 
from  family  resemblances  and,  before  it  is  said  to  be  due 
to  rickets,  the  head  of  the  mother  and  especially  that  of  the 
father,  should  be  visualized.  This  symptom  appears  early, 
but  is  continued  throughout  the  attack.  When  associated 
with  an  increase  in  the  parietal  and  frontal  eminences, 
which  occurs  as  the  result  of  an  actual  deposition  of  bone, 
and  which  does  not  appear,  as  a  rule,  until  after  6  or  8 
months,  the  head  assumes  the  characteristic  square  appear- 
ance which  is  distinctive  of  the  disease  (Fig.  32).  The 
circumference  of  the  skull  is  increased. 

In  young  infants  it  is  well  to  remember,  especially  after 
severe  labor  or  in  instrumental  cases,  that  the  shape  of  the 
head  may  become  irregular  or  flattened  as  the  result  of 


SYMPTOMS. 


193 


molding  or  of  pressure  of  the  forceps.  This  change  in 
contour,  also,  may  persist  for  some  weeks  or  months.  In 
fact  in  non-rachitic  breast-fed  babies  of  vigorous  develop- 


Fig.  32. — Square  outline  of  head  in  rickets. 

ment,  I  have  noted  it  as  late  as  8  months,  and  I  have  an 
impression  that  it  may  be  permanent  without  causing  any 
harm  to  the  brain.  This  should  be  borne  in  mind  when 

13 


194  RICKETS. 

deciding  individual  instances  as  to  their  rachitic  or  non- 
rachitic  origin,  and  a  careful  history  of  the  character  of  the 
labor  should  therefore  be  elicited. 

During  early  infancy  and  also  throughout  the  attack, 
digestive  disturbances  are  common.  In  themselves  they 
present  nothing  characteristic  of  the  disease,  and  whether 
they  appear  as  a  part  of  rickets  or  as  interloping  symptoms, 
or  as  a  consequence  of  it  or  even  if  they  possess  an  etiologic 
influence,  is  not  clear  in  the  nosology  of  this  affection. 
Certain  it  is,  however,  that  rarely  is  there  met  a  case  of 
rickets  in  which,  at  some  time  during  or  throughout  the 
milk-feeding  period  at  least,  that  digestive  orders  of  one 
type  or  another  are  absent.  Constipation  is  the  more  com- 
mon type  of  trouble,  or  this  may  alternate  with  diarrhea  in 
which  the  stools  present  features  of  fermentation  and  non- 
digestion.  Vomiting  is  rare.  The  stools  are  often  fetid. 
If  constipated,  they  may  appear  hard  and  nodular.  As  has 
been  stated,  it  cannot  be  determined  with  positiveness  that 
these  digestive  crises  possess  an  etiologic  influence.  There 
is  no  doubt,  however,  that,  at  least  in  a  measure,  they  are 
responsible  for  the  evidences  of  toxemia  which  are  com- 
mon to  rickets  and  which  show  themselves,  as  will  be  de- 
tailed later,  by  nervous  hyperirritability  with  a  tendency 
toward  convulsive  seizures. 

The  liver  and  spleen  are  quite  commonly  enlarged. 
More  significance  attaches  to  the  latter  than  to  the  former. 
It  is  difficult  to  determine  whether  splenic  enlargement  is  an 
essential  feature  of  the  disease.  My  impression  is  that  it  is 
not,  but  that  it  depends  upon  toxemia,  probably  of  intes- 
tinal origin,  or  it  may  be  secondary  to  a  tuberculous  process 
to  which  rachitic  children  are  so  frequently  subject.  Poly- 
glandular  enlargement  occurs,  too,  with  considerable  fre- 


SYMPTOMS.  195 

quency.  The  postcervical  glands  are  palpable,  as  are  the 
glands  of  the  axillae  and  those  in  the  region  of  the  groin. 
Undoubtedly,  in  many  instances,  the  enlargements  are 
tubercular,  but  not  infrequently  they  represent  simply  the 
evidences  of  general  toxemia. 

Dentition  is  delayed  in  those  cases  in  which  the  rickets 
appears  before  the  time  usually  recognized  as  the  physio- 
logic period  at  which  teething  should  be  inaugurated  (6  to 
8  months).  If  the  disease  appear  after  this  time  the  two 
lower  central  incisors  may  already  have  erupted.  This 
must  not  be  taken  as  a  sign  that1  rickets  does  not  exist. 
This  important  diagnostic  point  receives  emphasis  from 
Zappert.  The  subsequent  dentition  is  delayed.  Dentition 
is  often  irregular  and  rickety  children  may — although  care 
must  be  exercised  in  coming  to  this  conclusion,  which 
should  be  reached  only  after  every  other  possible  etiologic 
influence  has  been  eliminated — suffer  from  reflex  disturb- 
ances directly  due  to  teething,  on  account  of  the  hyper- 
excitability  of  the  nervous  system.  The  slight  irritation 
may  be  sufficient  to  produce  irritability,  nervousness, 
changes  in  disposition,  rises  in  temperature,  slight  conges- 
tions, as  coughs,  otitis,  and  conjunctivitis.  I  know  this  is 
a  dangerous  dictum  to  put  into  the  hands  of  the  general 
practitioner  and  am  conscious  that  it  has  been  combated  by 
much  eminent  authority.  I  feel,  however,  convinced,  from 
cases  which  I  have  carefully  studied,  that,  at  times  at  least, 
dentition)  and  rickets  produce  a  combination  of  etiologic 
factors  which  may  be  responsible  for  the  conditions  noted. 
At  least  no  other  factor  was  demonstrable  and  recovery  was 
hastened,  if  not  produced,  by  gum  lancing. 

Muscular  weakness,  to  which  reference  will  again  be 
made,  manifests  itself  early.  There  is  lacking:  a  feeling  of 


196  RICKETS. 

tone,  and  this  is  evidenced  by  the  inability  of  the  baby  to 
support  its  head  upon  the  shoulders  and  by  the  backward 
curvature  (rachitic  kyphosis)  of  the  spine  when  the  infant 
is  held  in  the  sitting  posture  (Fig.  33).  Ordinarily  an 
infant  should  be  able  to  support  its  head  by  the  end-  of  the 
second  or  third  month.  While  the  absence  of  the  power  so 
to  do  is  not  pathognomonic  of  rickets,  it  occurring  in  other 
conditions  (hydrocephalus  and  amaurotic  family  idiocy), 
its  association  with  the  other  symptoms  enumerated  forms 
a  highly  suggestive  phenomenon. 

An  ammoniacal  urine  is  a  common  occurrence  in  arti- 
ficially reared  infants.  It  results,  in  all  probability,  from 
the  excessive  feeding  of  fats  and  sugars  whereby  these  sub- 
stances are  but  partly  transformed  by  the  digestive  glands. 
This  results  in  the  formation  and  absorption  of  fatty  and 
other  acids  which  combine  with  the  alkaline  bases  of  the 
body,  producing  an  alkaline  reaction  of  the  urine  and  an 
increase  in  the  ammonium  output.  This  condition  is  espe- 
cially common  in  infants  who  show  the  other  symptoms  of 
early  rickets.  This  statement  must  not  be  taken  as  a  con- 
tradiction of  the  theory  which  emphasizes  the  possible 
etiologic  effect  of  the  deficiency  of  fat.  On  the  contrary  it 
accentuates  its  possible  truth,  viz.,  an  excessive  amount  of 
fat  may  be  fed  to  the  infant  and  yet  its  economy  may  re- 
ceive a  minimum  amount  on  account  of  its  perverted  trans- 
formation in  the  gut. 

The  following  symptoms,  therefore,  characterize  the 
symptom-complex  of  early  rickets,  and  may  be  nominated 
the  premonitory  features  of  the  disease, — not  that  it  has 
not  been  already  inaugurated,  but  that  the  progress  may,  in 
a  sense,  be  halted  by  proper  management.  They  are :  head- 
sweating,  craniutabes,  digestive  disturbances,  constipation, 


SYMPTOMS. 


197 


F'g-  33. — Rachitic  kyphosis. 


198 


RICKETS. 


late  dentition,  nervous  irritability,  muscular  weakness,  and 
ammoniacal  urine.  Craniotabes  alone  is  characteristic. 
The  rest,  individually,  signify  nothing,  but  the  entire  en- 
semble constitutes  an  entity  of  convincing  interest. 


Fig.  34. — Rickets.     Bulging  forehead,  enlarged  radii,  pot  belly,  skinny 
legs,  weak  muscles   (notice  child  cannot  stand),  flat-foot. 

OSSEOUS  CHANGES. 

Other  changes  in  the  skull  besides  craniotabes  occur. 
Great  interest  attaches  to  the  anterior  fontanette.  In 
rachitic  infants,  up  to  a  certain  age,  this  progressively  in- 


OSSEOUS    CHANGES.  199 

creases  in  size  with  the  growth  of  the  head.  Ordinarily  it 
should  be  closed  by  the  eighteenth  month.  Ossification  in 
rachitic  children  is  delayed  beyond  this  period,  sometimes 
extending  well  into  the  second  year.  While  the  membrane 
does  not  budge,  the  cranial  pulsation  may  be  distinctly  felt. 
The  sagittal  and  frontal  sutures  likewise  remain  open.  The 
forehead  at  times  bulges  and  the  frontal  eminences  are 
prominent  (Fig.  34).  The  facial  bones  are  also  involved, 


Fig.  35. — Rachitic  rosary. 

especially  the  superior  maxilla.     The  palate  consequently 
presents  a  highly  arched  appearance. 

Chest. — The  clavicles  frequently  present  abnormal  cur- 
vatures. The  sternum  is  not  uncommonly  depressed  below 
the  surface,  causing  the  characteristic  "chicken-breast"  ap- 
pearance or  it  may  be  unduly  prominent,  when  the  child  is 
said  to  be  "pigeon-breasted."  The  ribs  show  changes 
which  possess  considerable  diagnostic  import.  At  the 
costochondral  junction  enlargements  appear  which  may  not 
only  be  palpated,  but  which  are  distinctly  visible.  This  is 
called  "beading"  o<r  the  "rachitic  rosary"  (Fig.  35).  This 
is  only  produced  by  rickets.  It  must  be  borne  in  mind, 


200  RICKETS. 

however,  that  in  emaciated  infants  the  costochondral  junc- 
tion is  always  visible,  and  care  must  be  taken  not  to  regard 
this  as  rachitic  unless  there  occurs  distinct  enlargement. 
The  rosary  may  be  present  as  early  as  the  third  or  fourth 
month. 

The  whole  chest,  as  a  rule,  is  flattened  and  narrow, 
especially  in  the  upper  portion.  The  lower  portion  flares 
outwardly  and  may  appear  actually  everted.  This  causes 
the  formation  of  a  depression  running  outward  and  down- 
ward and  involving  usually  the  ninth,  tenth,  and  eleventh 
ribs.  It  constitutes  what  is  known  as  Harrison's  groove. 
The  amount  of  breathing  space  is  limited  on  account  of  the 
flattening  of  the  chest.  This  causes  an  improper  develop- 
ment of  the  lungs  and  may  constitute  a  potent  factor  in 
the  occurrence  of  those  pulmonary  infections  to  which 
rachitic  children  are  usually  subject.  Irregular  malforma- 
tion of  the  chest  may  appear.  One  side  may  be  prominent, 
the  other  flat,  and  serious  depressions  may  be  present. 

The  spine  presents  abnormal  curvatures.  Rachitic 
kyphosis  has  already  been  mentioned.  Scoliosis  is  common 
and  results  directly  from  muscular  traction  upon  the  softened 
bones  (Fig.  36).  These  curves  may  become  accentuated 
t.fter  the  child  begins  to  walk.  The  rachitic  curve,  of 
whatever  nature,  is  graded  and  can  usually  be  made  to 
disappear  unless  too  far  advanced,  by  causing  the  child  to 
lie  upon  its  stomach  or  to  bend  far  forward.  The  curve 
involves  many  vertebrae.  These  characteristics  distinguish 
the  rachitic  kyphosis  from  that  produced  by  tuberculosis  of 
the  spine,  in  which  the  backward  curvature  is  angular,  not 
gradual,  involving  but  two  vertebrae  as  a  rule  and  is  fixed 
(Fig.  37),  i.e.,  cannot  be  made  to  disappear  by  causing  the 
child  to  lie  upon  its  stomach  or  to  bend  far  forward.  In 


PLATE  XI 


Tubercular  kyphosis.    The  curve  involves  two  vertebrae.    In  rickets 
usually  four  or  five  are  involved  and  the  curve  is  gradual. 


OSSEOUS    CHANGES. 


201 


doubtful  instances,  an  X-ray  study  is  often  of  great  assist- 
ance in  making-  this  important  differentiation   (Plate  XI). 
The    rachitic    pelvis    is    flat    and    the    anteroposterior 


Fig.  36. — Rachitic  scoliosis. 

diameter  is  considerably  shortened.  This:  type  of  pelvis, 
together  with  spondylolisthesis,  may,  in  later  life,  give  rise 
to  serious  obstetric  complications.  The  pelvis  is  often  nar- 


202  RICKETS. 

rowed  laterally  and  may  be  so  obliquely,  due  to  the  develop- 
ment of  deformity  more  on  one  side  than  upon  another  as 
the  result  of  muscular  traction  and  pressure  after  the  weight 
of  the  body  rests  upon  the  undeveloped  legs. 

The  legs  of  the  rachitic  infant  are  not  commonly  curved, 
although  they  may  be.  The  normal  bowing  of  the  legs 
of  the  newborn  infant  must  not  be  confused  with  rickets. 
The  legs  are  small  and  undeveloped.  In  an  infant  18 
months  or  2  years  of  age  they  usually  have  the  development 
of  an  infant  6  to  8  months  of  age  (Fig.  34).  The  legs  are 
small,  flabby  and  hypotonic,  and  the  reason  for  the  inability 
to  walk  is  readily  recognized.  As  a  rule  the  deformities  do 
not  appear  until  the  weight  of  the  body  is  supported  by  the 
legs,  being  directly  due  to  the  combined  effect  of  pressure 
and  muscular  traction  upon  the  softened  bones.  Flat-foot 
also  occurs  (Fig.  34).  The  epiphyses,  just  above  the  ankles, 
are  commonly  enlarged,  but  not  to  the  same  extent  as  the 
epiphyses  of  the  forearms.  The  femur  is  rarely  involved 
alone,  although  I  have  witnessed  an  almost  complete  spiral 
twist  involving  one  femur.  Anterior  bowing  of  this  bone 
is  common. 

The  deformities  of  the  lower  extremities  may  be  worse 
on  one  side  than  on  the  other  and  they  may  assume  many 
forms.  For  simplicity,  however,  the  classification  of  Comby 
is  exceptionally  original  and  instructive,  He  causes  the 
following  figures  and  letters  to  represent  the  more  common 
deformities :  (  ) ,  parenthesis  or  O  legs  represent  bow-legs, 
or  genu  varum  (Fig.  38)  ;  capital  X,  knock-knee,  or  genu 
valgum;  K,  unilateral  genu  valgum;  D,  unilateral  genu 
varum  (Zappert).  Anterior  bowing  of  the  tibia  is  a 
common  deformity  (Fig.  39). 

The  upper  extremities  are  also  involved.    The  humerus 


OSSEOUS   CHANGES. 


203 


Fig.  37. — Tubercular  kyphosis,  showing  the  sharpness  of  the 
spinal  curvature.  Compare  with  X-ray  (Plate  XI)  of  similar  case  in 
another  patient. 


204 


RICKETS. 


may  present  thickenings  and  curves,  but  the  greatest  inter- 
est attaches  to  the  forearms,  especially  the  radii.  The 
forearm  may  be  bowed.  The  radii  commonly  present  an 
enlargement  of  the  epiphyses  just  above  the  wrists  (Fig. 


Fig.  38. — Pot  belly  and  bow-legs. 

34).  These  enlargements  may  be  slight  or  very  prominent 
and  are  pathognomonic  of  the  disease.  Although  it  does 
not  assume  the  same  prominence  as  it  does  in  scurvy, 
tenderness  of  the  bones  occurs  and  may  cause  the  child  to 
cry  when  handled. 


OSSEOUS   CHANGES. 


205 


The  bony  changes  are  progressive,  but  may,  as  pre- 
viously stated,  become  arrested  at  any  time.  After  recovery 
they  may  entirely  disappear.  On  the  contrary,  they  may  per- 
sist into  adult  life  and  thus  may  be  afforded  an  instance 


Fig-  39- — Rickets.    Anterior  bowing  of  tibia  and  pot  belly. 

of  the  hereditary  influence  in  those  cases  where  these 
changes,  especially  of  the  head,  are  visible  in  one  or  other 
parent  or  in  an  older  child.  Hereditary  influence  is  not, 
however,  always  easily  traced,  for  the  reason,  as  stated  be- 
fore, that  in  a  single  family  or  in  a  single  race  or  section 


206  RICKETS. 

of  the  country  the  same  etiologic  or  environmental  forces 
may  be  operative.  The  bones  become  unusually  hard  in 
instances  wherein  the  deformities  persist  beyond  the  sixth 
year.  It  is  noteworthy,,  however,  that  in  races  in  which 
rickets  is  common,  especially  in  the  colored  race,  in  which 
nearly  every  child  at  some  period  of  its  development  ex- 
hibits some  type  of  rachitic  deformity,  slight  or  severe,  very 
little  evidence  of  the  early  presence  of  the  affection  can  be 
noted  in  the  adult.  Neither  do  negro  women  suffer  from 
obstetric  complications  more  frequently  than  do  white 
females. 

Rachitis  of  adolescence  is  a  form  of  the  disease  which 
has  its  incidence  about  the  age  of  puberty.  It  is  little 
understood.  The  symptoms,  affecting  commonly  the  legs  of 
growing  boys,  which  may  become  bowed  or  knock-kneed, 
appear  at  the  time  of  heightened  physiologic  activity  when 
changes  are  noted  in  the  voice,  when  growth  appears  to  be 
stimulated,  and  when  hair  appears  upon  the  face,  under  the 
axillae,  and  over  the  pubic  region.  Flat-foot  may  develop 
at  this  time.  So-called  "growing  pains"  may  be  present, 
although  care  must  be  exercised,  otherwise  an  insidious 
attack  of  rheumatism  may  be  ignored  and  be  only  recog- 
nized when  the  distinctive  heart-murmur  occurs.  I  should 
say  that  growing  pains  are  more  commonly  rheumatic  than 
rachitic. 

MUSCULAR  WEAKNESS. 

This  is  an  early  and  valuable  sign  of  the  disease,  and  its 
etiologic  influence  upon  the  occurrence  of  the  bony  defor- 
mities has  been  noted.  The  inability  to  support  the  head, 
as  before  expressed,  is  directly  due  to  this  cause.  A  nor- 
mal infant  should  sit  up  unsupported  at  6  months.  It 


MUSCULAR   WEAKNESS. 


207 


should  crawl  at  9  months,  and  should  be  able  to  stand  by 
holding  to  a  chair  or  the  sides  of  its  crib  by  12  months,  and 
should  be  able  to  walk  without  assistance  by  15  or  18 
months.  These  physiologic  expressions  of  development  are 
absent  in  rickets.  Together  with  other  phenomena  these 
findings  form  valuable  diagnostic  data.  Walking  may  be 
delayed  until  beyond  the  second  and  third  years.  The 
inability  to  properly  use  the  legs  has  given  rise  to  the  term 
pseudo-rachitic  palsy,  which  must  be1  distinguished  from 


Fig.  40. — Rickets.     Pot  belly  and  protruding  umbilicus. 

paralysis  the  result  of  lesions  of  the  nervous  system,  espe- 
cially poliomyelitis.  This  distinction  is  largely  made  by 
the  presence  of  other  rachitic  features  and  normal  knee- 
jerks.  The  small,  underdeveloped,  flabby,  hypo  tonic  limbs 
(Fig.  34)  may  readily  suggest  atrophy  to  the  unwary,  but 
the  fact  that  the  condition  is  always  bilateral  and  sym- 
metrical is  against  poliomyelitis.  It  must,  however,  be 
remembered  that  rickety  infants,  as  well  as  others,  may 
suffer  from  this  disease  and  that  paraplegia  may  be,  though 
rarely,  the  type  of  paralysis  present. 

This  muscular  hypotonia  involves  the  muscles  of  the 
abdominal  wall  and  the  involuntary  musculature  of  the 
intestines  as  well,  and  is  directly  responsible  for  the  promi- 


208  RICKETS. 

nent  belly  which  is  so  characteristic  of  this  disease  (Figs. 
34,  38,  39,  and  40).  At  least  in  part,  it  is  responsible  for 
the  constipation  as  well.  The  latter  in  turn  causes  the  for- 
mation of  gases  which  assist  in  increasing  the  abdominal 
distention.  This  phenomenon  (meteorism)  I  believe  to  be 
an  important  factor  in  the  grave  prognosis  afforded  to  cases 
of  pneumonia  occurring  in  children  with  rickets. 

DENTITION. 

The  importance  of  the  irregularities  of  dentition  in  the 
early  diagnosis  of  rickets  has  been  described.  The  second 
dentition  likewise  partakes  in  this  irregularity.  The  first 
teeth  may  fall  out  as  soon  almost  as  they  appear,  leaving 
the  infant  toothless  until  the  second  dentition  takes  place. 
This  seriously  interferes  with  the  proper  development  of 
the  jaw,  which,  already  narrowed  by  the  arching  of  the  hard 
palate,  causes  the  second  teeth  to  be  crowded.  This  results 
in  overlapping  from  which  directly  ensue  erosions  and 
caries,  together  with  dwarfed  and  ridged  teeth.  This  is  not 
true  in  all  cases,  as  it  must  be  emphasized  that  the  fine 
teeth  of  many  of  the  African  race  appear  to  present  a  note- 
worthy contradiction  to  this  statement.  However,  it  may 
be  a  fact  that  the  disease  in  different  races  may  act  differ- 
ently, for  carious  and  eroded  teeth  appear  commonly  in 
rachitic  white  children.  The  teeth  may  be  notched  or  saw- 
like.  In  the  first  instance  they  must  be  distinguished  from 
Hutchinson's  teeth,  which  involve,  as  a  rule,  the  two  upper 
central  incisors,  and  which,  in  my  experience  at  least,  are 
very  rare.  I  have  met  this  deformity  but  two  or  three  times 
in  the  past  14  years,  although  I  have  seen  many  children 
suffering  from  all  varieties  of  luetic  disease. 


NERVOUS   SYSTEM.  209 

NERVOUS  SYSTEM. 

Aii  unstable  nervous  system  constitutes  a  part  of  the 
general  makeup  of  rachitic  infants  and  children.  Just  why 
this  is  so,  is  not  clear.  It  may  be,  in  the  light  of  quite  recent 
investigations,  with  reference  to  spasmophilia,  that  the  cal- 
cium balance  is  disturbed  as  the  result  of  perverted  func- 
tion or  disease  of  the  parathyroid  glands,  or  both.  Whether 
rickets  and  spasmophilia  have  a  uniform  basis  is  by  no 
means  clear.  Certain  it  is,  however,  that  an  increased 
excitability  of  nervous  tissue  is  more  commonly  met  in  the 
artificially  fed,  and  therefore  in  rachitic  infants  more  than  in 
others.  The  response  to  the  galvanic  current  is  more  rapid 
and  certain  and  requires  distinctly  less  current  (spasmo- 
philia) in  rachitic  children.  Tetany,  convulsions,  laryngo- 
spasm  (laryngismus  stridulus),  spasmus  nutans,  all  repre- 
sent evidences  of  increased  nervous  excitability  and  seldom 
occur  in  non-rachitic  subjects.  Intestinal  toxemia  and  con- 
stipation, themselves  due  to  rickets,  may  be  the  basic 
etiologic  influences  for  many  of  these  symptoms,  which 
disappear  or  are  decidedly  benefited  by  a  proper  apprecia- 
tion of  the  situation,  careful  intestinal  cleansing  and  an  in- 
telligent adjustment  of  the  diet. 

Blood. — Aside  from  secondary  anemia,  a  decrease  in  the 
hemoglobin,  which  does  not  appear  in  all  cases,  the  blood  of 
rickets  presents  nothing  of  interest  which  is  characteristic. 

Urine. — No  distinctive  changes  in  the  urine  are  noted. 
The  significance  of  the  ammoniacal  urine  of  early  infancy 
has  been  elsewhere  detailed  (Chapter  II,  page  112, — Fat 
Intolerance). 


14 


210  RICKETS. 

DIAGNOSIS  AND  DIFFERENTIAL  DIAGNOSIS. 

This  disease  is  distinguished  from  all  others  by  the 
osseous  changes.  The  early  recognition  of  rickets,  before 
these  changes  occur  or  just  at  their  beginning,  has  been 
described.  A  history  of  artificial  feeding  in  the  vast  major- 
ity of  cases,  headsweating,  craniotabes,  late  closure  of  the 
anterior  fontanelle,  irregularities  of  dentition,  muscular 
weakness,  enlarged  abdomen,  late  walking,  constipation, 
rachitic  rosary,  epiphyseal  enlargements,  curvatures  of  the 
spine  and  of  the  long  bones,  constitute  the  features  essen- 
tial for  diagnosis. 

It  seems  very  unlikely  that  one  should  err  by  confusing 
this  disease  with  another,  and  yet,  before  the  description  of 
it  by  Sir  Thomas  Barlow,  scurvy  was  at  first  regarded  as 
acute  rickets  and  frequently  confounded  with  it.  The 
individual  characteristics  of  the  two  diseases  are  so  palpably 
and  visibly  different  that  their  recognition  should  be  ac- 
complished without  difficulty  even  when  they  appear,  as 
they  sometimes  do,  simultaneously  in  the  same  subject.  The 
pain  and  tenderness  experienced  by  infants  with  scurvy, 
when  handled  or  moved,  is  never  so  severe  in  rickets  as  to 
cause  the  patient  to  lie  immobile  for  hours  in  one  position  in 
bed.  Bleeding  from  the  mucous  surfaces,  spongy  purple 
gums,  subperiosteal  hematoma,  anemia  and  purpura 
(hemorrhagic  tendency)  belong  to  scurvy  and  do  not 
occur  in  rickets  (Chapter  VI,  page  223). 

The  craniotabes  of  rickets  must  be  differentiated  from  a 
similar  condition  due  to  syphilis.  Clinically  this  is  made 
possible  by  a  history  of  repeated  miscarriages,  by  the  pres- 
ence of  copper-colored  skin  lesions,  mucous  patches,  des- 
quamative  lesions  of  the  palms  and  soles,  wasting,  and  by 


DIAGNOSIS  AND  DIFFERENTIAL  DIAGNOSIS.        211 

the  possible  incidence  of  bone  involvement  or  deep  ulcera- 
tions.  Serologically,  the  Wassermann  reaction  offers  in- 
valuable confirmatory  evidence.  The  same  clinical  data  are 
of  assistance  in  differentiating-  the  eroded  second  teeth  of 
rickets  from  those  of  syphilis.  The  characteristics  of 
Hutchinson's  teeth  have  been  described.  It  must  be  remem- 
bered that  the  two  diseases  may  appear,  especially  in 
negroes,  in  the  same  individual. 

From  tuberculosis  of  the  bones  it  is  not  always  so*  easy 
to  distinguish  this  disease.  A  careful  history  is  important. 
The  presence  of  ulcerations,  pulmonary  lesions,  and  the 
positive  results  obtained  from  the  von  Pirquet  and  the 
Moro  test  may  assist  in  solving  the  problem.  It  may  not, 
however,  always  be  thus  easily  accomplished  on  account  of 
the  frequent  association  of  these  two  diseases  in  the  same 
individual.  The  digestive  disturbances  and  constipation 
peculiar  to  rickety  children  may  be  associated  with  irregular 
rises  in  temperature  and  emaciation.  This  causes  added 
confusion  in  eliminating  obscure  tuberculosis,  and  should 
always  be  borne  in  mind.  From'  tuberculosis  of  the  spine 
(Pott's  disease)  the  distinction  has  already  been  made 
(Chapter  V,  page  200). 

The  head  of  rickets  must  be  differentiated  from,  the 
enlargement  due  to  hydrocephalus.  In  the  latter  the  charac- 
teristic squareness  is  lacking  in  the  outline  of  the  head. 
The  sides  are  flanged  outward  and  upward  from,  a  com- 
paratively small  and  pointed  forehead,  causing  the  for- 
mation of  a  vast  expanse  of  vault  consisting  of  thinned-out 
bone.  The  anterior  fontanelle  is  not  only  opened  but 
bulges,  and  the  sutures  are  patent,  while  the  marked  dis- 
proportion between  the  size  of  the  head  and  that  of  the  face, 
which  is  small,  is  evident  at  a  glance.  The  superficial  veins 


212 


RICKETS. 


about  the  lateral  aspects  of  the  forehead    (temples)    are 

very  prominent. 

The  points  of  difference 
between  polio-myelitis  and  the 
pseudo-palsies  of  rickets  have  ' 
been  detailed  (Chapter  V,  p. 
207).  Amaurotic  idiocy  is 
also  characterized  by  muscular 
weakness.  This  disease  is  al- 
most exclusively  confined  to 
Russian  Jews.  It  may  present 
a  history  of  heredity.  Eye 
symptoms  develop.  The  char- 
acteristic cherry-red  spot  (Hey 
Tyne)  is  seen  by  the  ophthal- 
moscope upon  the  macula 
lutea.  Blindness  and  convul- 
sions supervene,  and  death  is 
the  inevitable  and  humane  re- 
sult. 

Cases  in  which  intense  an- 
terior curvature  of  the  lower 
spine  (lordosis)  causes  the  hips 
to  become  prominent  and  mis- 
placed backward  and  upward, 
and  especially  when  associated 
with  symmetrical  bowing  of 
both  femurs,  and  in  which  the 

Fig.  4i.-Doubie  congenital       lower  portions  of  the  body  ap- 
dislocation  of  hip,  to  be  dis-       pear   shortened    and   likewise 

tinguished  from  rachitic  lordo-         where    ^         jt    jg    somewhat 

sis  or  anterior  curvature  of  the 

spine.  waddling,  often  give  the  im- 


PROGNOSIS.  213 

pression  of  double  congenital  dislocation  of  the  hips  (Fig. 
41).  A  careful  examination  will  reveal  that  motion  is  not 
limited  in  any  direction,  and  that  the  heads  of  the  bones  are 
properly  placed.  An  X-ray  examination  affords  absolute 

data. 

COMPLICATIONS. 

Digestive  disturbances  have  been  mentioned.  The 
liability  to  convulsions  and  to  other  spasmodic  diseases, 
laryngospasm,  tetany,  carpopedal  spasm,  spasmus  nutans, 
nystagmus,  infantile  convulsions,  has  been  discussed  as  well 
as  the  predisposition  to  tuberculosis  and  the  association  of 
scurvy  with  this  disease  in  the  same  individual.  The  diffi- 
culties attending  the  eruption  of  the  milk  teeth  in  rachitic 
subjects  need  no  further  emphasis.  Infants  and  children 
with  rickets  suffer  from  exudative  phenomena — eczemas, 
intertrigo — and  are  particularly  prone  to  bronchitis,  which 
has  a  tendency  to  become  chronic  and  extensive,  and 
to  broncho-  and  lobar  pneumonia.  The  severity  of  all 
infections  is  intensified  when  occurring  ini  these  patients, 
and  the  prognosis  is  always  adversely  influenced.  Bony  de- 
formity, especially  that  involving  the  pelvis,  may  be  per- 
manent and  seriously  affect  maternal  and  infantile  mor- 
bidity and  mortality  on  account  of  the  subsequent  dystocia. 

PROGNOSIS. 

Complete  recovery  from  rickets  is  possible  and  common. 
The  liability  of  the  disease  to  be  spontaneously  arrested  is 
frequently  emphasized,  especially  when  the  infant  reaches 
that  period  where  it  receives  food  other  than  cows'  milk 
alone.  The  disease  itself  is  rarely  fatal,  its  lethal  influence 
being  exerted  upon  those  conditions  dangerous  in  them- 
selves and  already  mentioned  as  occurring  as  complications. 


214  RICKETS. 

TREATMENT. 

Prophylaxis. — This  is  best  afforded  by  breast  feeding. 
Either  the  milk  of  the  mother  or  that  of  a  wet-nurse,  if 
feasible,  should  be  supplied.  Breast  feeding,  however, 
should  not  be  continued  beyond  the  first  year.  In  fact  if 
the  infant  has  cut  several  teeth  and  the  season  of  the  year  is 
not  warm,  recourse  may  be  had  to  solid  or  semisolid  food 
at  9  or  10  months,  and  in  some  instances  earlier.  I  believe 
it  to  be  advisable  to  offer  such  foods  as  well-cooked  cereals, 
especially  oatmeal,  rice,  barley,  meat-juice,  fruit-juices, 
eggs,  and  broth  made  from  vegetables  (Chapter  III,  page 
146)  at  this  period  of  the  breast  feeding.  These  substances 
should  be  given  in  small  amounts  and  should  be  simply,  but 
well,  cooked,  and  exhibited  mashed.  The  broth  made  from 
vegetables,  slightly  salted,  may  be  given  ad  libitum  as  a 
drink  instead  of  water.  It  supplies  mineral  substances,  is 
antacid  and  laxative. 

The  greatest  difficulty  arises  in  preventing  the  occur- 
rence of  rachitic  symptoms  in  infants  who  are  artificially 
fed.  Much  may  however  be  accomplished  if  the  case  be 
watched  and  if  simple  though  effective  measures  be  conscien- 
tiously pursued.  Infants  require  fat  and  they  also  require 
protein  in  sufficient  amount,  if  rickets  is  to  be  forestalled, 
and  yet  both  these  substances  may  be  productive  of  serious 
digestive  disturbance.  This  view,  with  reference  to  the  in- 
digestibility  of  protein,  does  not  receive  support  from  the 
present-day  teaching  of  the  German  school  of  pediatrists 
represented  by  Finkelstein  and  his  confreres.  Reference 
has  already  been  made  to  this  (Chapter  II,  page  104).  Many 
American  pediatrists  have  been  profoundly  influenced  by 
the  German,  idea.  I  wish  to  repeat  that  my  own  view, 
based  upon  considerable  clinical  experience,  does  not  per- 


TREATMENT.  215 

mit  me  to  subscribe  to  the  dictum  that  cow-protein  (un- 
changed mechanically  or  chemically)  may  be  administered 
in  incalculable  quantities  without  harm.  I  believe  there- 
fore, and  have  been  able  to  prove,  at  least  to  my  own  satis- 
faction, that  it  is  important  to  commence  artificial  nourish- 
ment with  small  amounts  of  protein.  This  cannot  how- 
ever be  continued  too  long,  else  rickets  will  occur.  The 
amount  must  be  slowly  but  persistently  increased,  and  as 
soon  as  the  signs  of  protein  intolerance  manifest  them- 
selves measures  must  be  taken,  if  not  to  reduce  the  amount 
(and  this  I  do  not  advise  at  once),  to  modify  it  either 
mechanically  or  chemically.  The  methods  for  doing  this 
have  been  discussed  under  the  dietetic  treatment  of  protein 
intolerance  and  under  Marasmus  (Chapters  II  and  IV, 
pages  1 06  and  172). 

The  same  ideas  apply  to  fat.  Fat  is  necessary  and  must 
be  fed  in  sufficient  amounts,  and  as  soon  as  the  evidences  of 
intolerance  appear,  it  too  must  be  modified  chemically 
(Chapters  II  and  IV,  pages  no  and  179).  It  may  not  be 
amiss  to  repeat,  for  the  sake  of  emphasis,  that  cow-fat 
differs  from  the  fat  of  human  milk,  and  therefore  4  per 
cent,  should  never  be  exceeded,  and  that,  as  a  matter  of 
routine  policy,  it  is  safer  to  feed  less  than  this  amount. 
Where  cow-fat  cannot  be  tolerated  at  all,  small  doses  of 
olive  oil  may  be  given  on  an  empty  stomach  without  gastric 
disturbance  and  with  considerable  benefit  in  many  cases. 
The  same  is  true,  though  to  a  less  degree,  of  codliver  oil, 
which  may  be  advantageously  employed  as  well,  by  inunc- 
tion. 

While  sugar  is  necessary  to  produce  heat  and  to  con- 
serve protein,  and  while*  it  is,  in  my  experience,  usually 
well  tolerated,  care  should  be  exercised  not  to  feed  it  in 


216  RICKETS. 

excessive  amounts  to  the  neglect  of  protein  and  fat.  It 
makes  fat  babies,  but  weak  and  rickety  ones.  This  is  the 
reason  why  condensed  milk  continuously  used  as  a  routine 
food  must  be  condemned.  It  is  satisfactory  as  a  go-between, 
as  a  substitute  for  a  brief  period,  but  not  longer  without 
additional  aliment.  From  6  to  7  per  cent,  of  sugar  should 
never  be  exceeded.  My  routine  preference  is  cane-sugar, 
for  reasons  already  stated. 

Inasmuch  as  they  contain  mineral  substances  and  pro- 
tein as  well  as  starch,  which,  like  sugar,  conserves  protein, 
I  believe  that  cereal-waters  for  general  use  serve  better  as 
milk  diluents  than  plain  water.  This  preference  refers 
especially  to  oatmeal  and  barley-water. 

All  infants  artificially  fed  should  receive  meat-juice 
early,  and  fruit- juices  as  well,  on  account  of  their  mineral 
content  and  also  because  they  are  antacid,  stimulating  to 
the  alimentary  mucosa,  and  because  they  are  quickly 
digested  and  absorbed.  For  this  purpose  beef-blood  ex- 
pressed from  fresh  meat  is  administered  in  quantities  of 
from  y2  to  2  drams  three  times  a  day,  exactly  one-half 
hour  before  feeding,  and  the  vegetable  broth  above  re- 
ferred to  should  be  given  freely  (Chapters  III  and  IV, 
pages  144  and  176). 

Lime-water  is  of  questionable  service.  It  probably 
renders  no  assistance  in  the  conservation  of  lime-salts  in 
the  economy.  It  may  disturb  digestion  or  produce  consti- 
pation. In  some  instances,  however,  where  these  effects 
are  not  noted,  it  may  be  added  in  the  amounts  of  from  5  to 
10  per  cent,  of  the  formula  as  part  of  the  diluent.  It  is  my 
belief  that  pasteurization  or  sterilization  of  milk  (the  latter 
should  not  be  administered  too  long  on  account  of  the  pos- 
sibility of  scurvy)  is  not  productive  of  rickets.  However, 


TREATMENT.  217 

unheated,  strictly  fresh,  certified  milk  is  preferable,  if 
obtainable. 

By  the  time  an  infant  reaches  9  months  or  a  year,  it 
should  receive  undiluted  cows'  milk.  The  same  additions 
to  the  diet,  as  mentioned  above  under  Breast  Feeding, 
should  be  given  to  babies  who  are  being  artificially  reared, 
as  soon  as  they  erupt  several  teeth. 

Sunshine,  fresh  air,  proper  breathing  space,  good  sleep- 
ing quarters,  and  warm  clothing  are  essentials  in  the  pre- 
vention of  rickets.  They  are,  unfortunately,  not  always 
obtainable  by  those  who  need  them  most.  Infants,  espe- 
cially feeding  cases,  should  not  be  kept  in  hospitals  for  any 
great  length  of  time.  They  do  badly  as  a  rule,  and  fre- 
quently develop  malnutrition  and  rickets. 

To  summarize,  it  may  be  stated  that  the  prophylaxis 
against  rickets  consists  in  breast  milk,  properly  adapted 
coins'  milk  containing  a  sufficiency  of  fat  and  protein  in 
digestible  form,  a  proper  amount  of  sugar,  cereal-waters, 
meat-juices,  fruit- juices,  vegetable  broths,  the  early  use  of 
solid  and  semisolid  food,  and  a  wholesome  environment 
which  secures  to  the  infant  the  common-sense  requirements 
of  a  normal  existence, 

Dietetic  Management  Beyond  the  First  Year. — Besides 
good  milk,  the  main  reliance  should  be  placed  upon  a  vege- 
table diet  rich  in  salts,  iron,  and  lime.  Spinach  is  an 
unusually  serviceable  substance.  The  method  of  its  prep- 
aration is  discussed  under  Chapter  III,  page  147.  Mashed 
skinned  peas,  mashed  skinned  lima  beans,  tender  string 
beans,  carrots,  stewed  celery,  stewed  or  raw  onions,  mashed 
baked  potatoes,  are  also  valuable.  Eggs,  soft-boiled  or 
poached,  form  a  splendid  addition  on  account  of  their  high 
fat  and  protein  content,  and  also  because  they  contain 


218  RICKETS. 

phosphorus.  Broths  and  soup  and  broiled  scraped  beef 
should  be  added  as  speedily  as  possible.  All  foods  should 
be  simply,  but  well,  prepared,  and  fed  in  amounts  that  will 
not  overburden  the  digestion.  Should  trouble  arise,  no 
hesitancy  should  prevent  a  speedy  recourse  to  the  artificial 
digestants,  pancreatin,  taka-diastase,  and  pepsin. 

Medicinal  Treatment. —  There  is  no  doubt  that  phos- 
phorus administered  in  suitable  form  exerts  a  valuable  cura- 
tive influence,  not  only  upon  the  pathologic  processes  which 
involve  the  bone,  but  upon  the  irritated  nervous  system  as 
well.  It  appears,  from  recent  experiments,  to  increase 
calcium  retention.  It  may  be  given  alone  or  in  combination 
with  olive  oil  or,  preferably,  codliver  oil.  My  experience 
verifies  the  statement  of  Holt,  that  a  vegetable  fat  such  as 
olive  oil  is  often  better  borne  than  an  animal  fat.  Espe- 
cially is  this  true  if  the  olive  oil  be  mixed  with  a  small 
amount  of  grape-juice.  Codliver!  oil  itself  is  a  valuable 
agent  on  account  of  its  alterative  qualities,  the  result  of  the 
iron  which  it  contains,  and  because  of  its  direct  food  value. 
It  supplies  fat  in  a  suitable  form  without,  as  a  rule,  pro- 
ducing gastric  disturbance.  As  previously  stated,  it  may  be 
employed  by  inunction.  A  combination  of  phosphorus  and 
codliver  oil  is  represented  by  the  classical  prescription  of 
Kassowitz : — 

B  Phosphorus    i  part. 

Codliver  oil  1000  parts. 

Sig. :    f3j  t.  i.  d.  one-half  hour  after  food. 

Jacobi  years  ago  recommended  phosphorus  -  as  a  valuable 
therapeutic  agent  in  the  treatment  of  rickets.  The  usual 
dose  for  an  infant  under  i  year  is  Vsoo  grain  three  times 
a  day. 


TREATMENT.  219 

The  preparations  of  calcium — calcium  lactate  gr.  iij  to 
gr.  x,  t.  i.  d.,  or  the  syrup  of  lactated  calcium,  f3j,  t.  i.  d.,  or 
calcium  in  combination  with  phosphorus,  as  found  in  the 
syrup  of  hypophosphites  compound  of  the  U.  S.  P. — are 
of  service  too.  Their  direct  effect  in  staying  the  rachitic 
processes  has  not  been  fully  demonstrated,  but  they  un- 
questionably, especially  in  the  light  of  modern  investiga- 
tion, exert  a  soothing  influence  upon  nervous  tissue  and 
tend  to  prevent  the  occurrence  of  periodic  or  permanent 
nervous  phenomena. 

When  nervous  excitability  does  not  appear  as  a  promi- 
nent feature  and  where  muscle  weakness  is  unusually  promi- 
nent, I  have  come  to  regard  strychnine  in  the  form  of  the 
sulphate  gr.  1/20o  to  gr.  1/i00  t.  i.  d.  as  a  beneficent  tonic 
when  continued  over  a  considerable  period  of  time.  Such 
alteratives  and  tonics  as  the  syrup  of  the  iodid  of  iron 
IH.V-X  t.  i.  d.  and  the  syrup  of  hydriodic  acid  tn.x-xv,  alone 
or  together,  or  both  combined  with  the  simple  or  the  com- 
pound syrup  of  hypophosphites,  find  a  valuable  field  of 
service  in  the  presence  of  anemia,  chronic  bronchitis,  or 
glandular  enlargements.  These  agents  may  be  constipating 
or  may  interfere  with  digestion.  For  this  reason  care  must 
be  exercised  in  their  administration.  The  combination  of  a 
simple  tonic  laxative,  as  the  aromatic  fluidextract  of  cascara 
sagrada,  may  render  valuable  assistance. 

My  assistants  in  my  clinic  at  the  Mt.  Sinai  Hospital 
in  Philadelphia  (Drs.  J.  L.  Werner  and  I.  Rubin)  have 
under  similar  conditions  obtained  excellent  results  by  ad- 
ministering the  following  by  hypodermic  injection  three 
times  a  week,  especially  where  the  anemia  is  associated  with 
much  splenic  enlargement: — 


220  RICKETS. 

B  Ferri   citratis   viridis    gr.  %o 

Sodii    cacodylatis    gr.  l/2 

Sodii  glycerophosphat gr.  il/2 

Aquae  destill.    (sterile)     TT\.XX 

M.  et  ft.  ampulla  no.  j. 

Digestive  disturbances  are  met  as  they  arise,  on  gen- 
eral lines.  An  occasional  intestinal  cleansing  with  castor 
oil  is  serviceable.  For  the  persistent  constipation  small 
doses  of  gray  powder  gr.  y2  t.  i.  d.  or  oil  enemas  three 
times  a  week,  abdominal  massage  or  Philip's  milk  of  mag- 
nesia nix-xl  to  every  or  to  every  other  bottle,  according  to 
effect,  or  some  palatable  preparation  of  cascara  "lx-xxx  once 
or  thrice  a  day  are  serviceable.  Of  late  I  have  been  im- 
pressed with  the  value  of  some  of  the  newer  preparations 
of  liquid  paraffin  (Chapter  VIII). 

Non-medicinal  Treatment.- Frequent  cleansing  of  the 
skin  surface  is  useful,  especially  when  followed  by  thorough 
rubbing.  It  not  only  improves  the  circulation  of  the  skin, 
but  causes  deeper  and  fuller  respirations,  and  therefore 
assists  in  maintaining  the  symmetry  of  the  chest. 

The  first  teeth  of  the  rickety  child  should  receive  dental 
care.  All  cavities  should  be  filled  with  cheap  material  and 
all  hopelessly  decayed  teeth  should  be  extracted.  The 
mouth  should  be  kept  in  as  aseptic  condition  as  possible.  In 
this  way  alone  may  obscure  toxemias,  digestive  derange- 
ments, and  skin  rashes  be  avoided.  This  applies  to  other 
diseases  as  well  as  to  rickets. 

Much  may  be  done  by  way  of  prophylaxis  to  prevent 
the  occurrence  of  severe  deformities  by  making  an  early 
diagnosis  of  the  disease.  Rickety  children  should  not 
be  made  to  stand  before  they  are  able  or  before  they  do  so 
voluntarily.  After  they  do  commence  to  stand  the  in- 
dividual should  be  studied,  and  if  his  legs  appear  unusually 


TREATMENT.  221 

small  and  weak,  he  should  not  be  encouraged  to  bear  his 
weight  upon  them.  Braces  should  not  be  applied  until  the 
child  walks,  but  should  then  be  provided  early  and  be  worn 
continually,  either  to  prevent  the  occurrence  of  deformity  or 
to  secure  its  early  correction.  A  discussion  of  the  types  of 
braces  or  of  the  various  orthopedic  maneuvers  employed  for 
the  correction  of  the  osseous  deformities,  temporary  or  per- 
manent, are  beyond  the  scope  of  this  volume  and  cannot  be 
treated  in  detail. 


CHAPTER  VI. 
SCURVY. 

Definition. —  Scurvy  is  a  disease  of  metabolism  depend- 
ing upon  an  as  yet  unknown  etiologic  factor.  It  is  con- 
sistently associated  with  artificial  feeding.  The  diet  is 
commonly  lacking  in  raw  animal  and  vegetable  products. 
It  is  characterized  by  a  premonitory  period  of  peevishness 
and  irritability,  which  is  later  followed  by  hyperesthesia  and 
actual  pain  and  tenderness  in  the  bone.  Hematuria  and 
subperiosteal,  gingival,  and  visceral  hemorrhages  complete 
the  clinical  picture. 

ETIOLOGY. 

The  actual  determining  cause  is  unknown.  The  disease 
is  probably  non-infectious,  although  the  subnutritional  state 
predisposes  to  secondary  infection.  Metabolic  disarrange- 
ment is  probably  responsible  for  the  presence  in  the  blood 
of  some  as  yet  undetermined  chemical  compound  or  com- 
pounds from  the  effects  of  which  the  symptoms  arise.  The 
disease  occurs  with  the  greatest  rarity,  if  at  all,  in  the 
breast-fed  and  only  in  those  cases  in  which  maternal  nursing 
has  been  continued  over  too  long  a  time  ( 15  or  16  months). 

Children  fed  for  a  long  period  upon  the  patented  foods, 
which  are  made  with  or  without  milk,  appear  to  suffer  most. 
Plain  boiled  milk,  contrary  to  the  usual  teaching,  does  not, 
if  the  boiling  be  but  momentary,  appear  often  to  produce 
scurvy — at  least,  in  my  experience.  Prolonged  boiling,  on 
the  other  hand,  with  the  addition  of  a  patent  food,  deter- 
mines most  cases.  It  is  uncommon  under  3  months.  Most 
cases  appear  after  6  months.  It  is  rare  after  18  months. 
(222) 


CLINICAL  HISTORY  AND  SYMPTOMATOLOGY.        223 

PATHOLOGY. 

The  characteristic  lesion  of  the  disease  is  distinguished 
by  hemorrhage  under  the  periosteum  of  the  long  bones  and 
by  hemorrhagic  infiltration  of  the  internal  organs.  These 
extravasations  of  blood  are  large  or  small,  and  may  be 
microscopic.  Bone  changes  also  occur,  but  are  less  marked 
than  in  rickets.  Epiphyseal  separations  are  common.  The 
extravasated  blood  undergoes  absorption  and  organization, 
leaving  behind  hard,  thickened  areas. 

CLINICAL  HISTORY  AND  SYMPTOMATOLOGY. 

The  infant  has  never  received  breast  milk  or,  if  it  has, 
it  has  been,  as  a  rule,  discontinued  early  and  usually  for  an 
insufficient  reason.  On  the  other  hand,  a  history  of  pro- 
longed exclusive  breast  feeding  may  be,  in  very  rare  in- 
stances, obtained.  Personally  I  have  never  met  a  case.  It 
has  been  placed  upon  an  indifferently  modified  cows'  milk, 
alone  or  in  combination  with  a  patent  food.  Frequently,  a 
history  consisting?  of  the  exclusive  'feeding  of  condensed 
milk  is  given.  In  most  instances  the  food  has  been  sub- 
jected to  prolonged  boiling,  although  this  is  not  constant. 
The  infant  has  never  received,  or  at  least  has  received  very 
irregularly,  animal  or  vegetable  juices.  The  baby  may  or 
may  not  have  been  placed  upon  the  artificial  food  on  ac- 
count of  a  digestive  upset  while  on  the  breast  (very  com- 
mon reason),  or  there  may  be  a  digestive  upset  after  being 
placed  upon  the  modified  milk.  For  this  reason  one  patented 
food  after  another  has  been  tried.  The  distinguishing 
point  to  remember  is  that  the  food  lacked  freshness,  or  per- 
haps, what  is  a  somewhat  poor  but  more  expressive  state- 
ment, it  lacked  the  vital  principle  of  rawness. 


224  SCURVY. 

The  sweet-dispositioned  baby  which  has  been  growing 
fat,  now  becomes  irritable  and  peevish.  It  cries  and 
whimpers  when  it  is  approached,  and  especially  when  picked 
up  or  while  being  bathed.  If  it  has  zvalked,  it  now  refuses 
to  do  so,  or  it  will  not  stand,  crying  when  placed  upon  its 
feet.  This  occurring  in  a  previously  healthy  infant  of  1 1  or 
more  months  of  age  is  so  characteristic  of  this  disease  that 
it  assumes  almost  pathognomonic  importance.  A  pallor  of 
the  skin  is  noted  and  the  child  is  content  to  lie  in  its  crib 
undisturbed  for  days  at  a  time.  This  is  a  very  characteris- 
tic and  early  feature.  The  bowels  may  be  normal,  or  there 
may1  appear  evidences  of  indigestion  and  the  movements 
may  contain  visible  or  occult  blood.  Helena  is  rare. 
Hematuria  occurs  and  may  be  the  only  symptom.  The 
amount  of  blood  varies  as  the  intensity  of  the  disease.  It 
may  only  be  detected  by  the  microscope.  Albumin  and 
casts  are  usually  present  with  the  blood,  but  they  are  not  an 
essential  part  of  the  disease  and  may  represent  a  true  com- 
plicating nephritis.  Pus,  from  an  associated  pyelitis  or 
cystitis,  has  also  been  found  in  the  urine. 

A  characteristic  symptom  of  the  disease  is  subperiosteal 
hemorrhage.  It  may  be  the  first  intimation  of  the  real 
nature  of  the  child's  indisposition.  The  previous  ill-health 
described  has  been  present,  but  an  incorrect  interpretation 
has  been  placed  upon  it,  the  most  likely  diagnosis  to  have 
been  made  being  rheumatism.  In  the  history  it  is  so  com- 
monly stated  by  the  mother  that  her  infant  has  been  treated 
for  rheumatism  that  suspicion  of  scurvy  should  be  aroused 
by  this  fact  alone.  The  hemorrhages  occur  usually  under  the 
periosteum  of  the  long  bones,  most  often  the  femur  and 
tibia — the  lower  extremities  being  affected  with  greater 
frequency  than  the  upper.  The  subperiosteal  extravasations 


PLATE  XII 


The  appearance  of  the  gums  in  a  case  of  infantile  scurvy. 
Note  swollen  condition  and  purplish  discoloration,  especially 
around  the  bases  of  the  erupted  teeth.  This  condition  is 
pathognomonic  of  the  disease. 


CLINICAL  HISTORY  AND  SYMPTOMATOLOGY.       225 

of  blood  cause  swellings,  which  appear  with  more  or  less 
suddenness.  The  swelling  is  large  or  small,  as  the  case  may 
be:  is  more  or  less  pyramidal  in  shape,  occupying  usually 
the  lower  third  of  the  bone  near  the  joint,  but  not  involving 
it;  is  of  a  doughy  feel,  and  may  give  the  sensation  of  fluid 
under  tension,  distinct  fluctuation  being  rarely  experienced 
(Fig.  42).  Fig.  43  represents  the  same  case  cured,  but  still 
showing  evidences  of  rickets.  The  superficial  veins  over  the 
swelling  may  be  prominent  and  the  extremity  below  is  often 
edematous.  The  edema  may,  however,  be  present  in  both 
feet,  being  independent  of  the  pressure  exerted  by  the  ex- 
travasated  blood. 

These  hemorrhages  may  occur  in  any  part  of  the  body, 
either  into  the  viscera,  the  walls  of  the  intestine,  the  menin- 
ges,  or  into  the  cavity  of  the  orbit.  The  last  causes  sud- 
den and,  for  a  time,  unexplainable  unilateral,  rarely  bi- 
lateral, exophthalmos.  The  blood  may  find  its  way  into  the 
eyelids  or  conjunctiva,  giving  the  appearance  of  the  so- 
called  black  eye  which  is  erroneously  thought  to  be  due  to 
trauma.  The  extravasated  blood  causes  pain  by  pressure. 
As  a  result  the  infant  lies  in  a  more  or  less  characteristic 
attitude.  The  thighs  are  usually  abducted  and  rotated  out- 
ward. Epiphyseal  separation  may  occur  as  a  result  of  the 
large  extravasations  of  blood.  This  condition  may  be 
erroneously  diagnosed  epiphysitis,  the  underlying  scurvy 
being  entirely  ignored.  In  fact  all  real  instances  of  appar- 
ently primary  or  spontaneous  epiphysitis  should  be  regarded 
as  scorbutic  until  it  is  conclusively  proven  that  they  are  not. 
Aside  from  the  hemorrhagic  symptoms  which  are,  in  them- 
selves, convincing,  the  X-ray  provides  a  very  easy  and 
valuable  means  of  distinguishing  an  epiphyseal  separation 
due  to  hemorrhage,  from  an  acute  epiphysitis.  Likewise  in 


226  SCURVY. 

the  latter  the  differential  leucocyte  count  would  indicate  an 
increase  in  the  polymorphonuclear  cells. 

The  mouth  appearance  is  characteristic.  The  gums, 
especially,  if  the  teeth  are  not  present,  may  appear  normal. 
On  the  other  hand,  they  may  be  spongy  and  red,  bleeding 
with  great  ease.  Most  distinctive  is  the  picture  if  the  teeth 
have  been  erupted.  Around  the  base  of  each  tooth,  or  per- 
haps covering  the  whole  cusp,  except  the  cutting  edge,  the 
gums  are  purplish,  red,  and  swollen  (Plate  XII).  The 
rest  of  the  gum  may  appear  normal  or,  as  the  result  of 
secondary  infection,  gingival  ulceration  has  been  noted. 
Extravasated  blood  into  the  mucous  membrane  of  the  hard 
palate  may  appear  as  a  more  or  less  circumscribed,  bluish 
swelling. 

Hemorrhages  into  the  viscera,  as  the  liver  or  spleen,  or 
into  the  walls  of  the  intestines  (Still)  occur,  but  are  very 
difficult  to  recognize  when  present  alone.  The  blood  shows 
nothing  typical  other  than  the  evidences  of  symptomatic 
anemia,  slow  clotting,  and;  leucocytosis  as  the  result  of  the 
hemorrhages.  The  hemoglobin  averages  about  45  per 
cent.,  but  may  go  lower,  and  the  red  cells  number  about 
2.500,000  or  less.  Care  should  be  taken  not  to  regard  the 
presence  of  leucocytosis  as  an  evidence  of  inflammatory 
disease,  else  the  diagnosis  may  be  clouded.  In  this  connec- 
tion the  differential  count  will  reveal  tlie  absence  of  an  in- 
crease in  the  polymorphonuclear  cells  when  the  leucocytic 
excess  is  not  dependent  upon  a  primary  or  secondary  infec- 
tious process.  Purpuric  eruptions  occur,  but  are  neither 
constant  nor  as  common  as  usually  supposed.  The  single 
lesions  may  present  the  appearance  of  a  traumatic  ecchy- 
mosis,  and  in  fact  may  be  directly  dependent  upon  slight 
trauma  inflicted  simply  by  handling  the  child.  The  de- 


CLINICAL  HISTORY  AND  SYMPTOMATOLOGY.        227 

pendent  portions  of  the  body  are  more  commonly  involved. 
Epistaxis,  while  rare,  has  been  noted.  The  temperature  of 
scurvy  cases,  while  often  normal,  is  just  as  frequently 
elevated  to  101°  F.  or  102°  F.  The  fever  is  most  likely 


Fig.  42. — Scurvy.    Subperiosteal  hematoma  of  right  thigh, 
edema  of  legs  and  left  thigh. 

dependent  upon  the  absorption  of  aseptic  blood-clot  and 
fibrin.  Hyperpyrexia  is  rare  and  is  usually  dependent  upon 
secondary  infection  of  the  blood-clot,  or  is  due  to  pyelitis 
or  cystitis. 


228  SCURVY. 

DIAGNOSIS  AND  DIFFERENTIAL  DIAGNOSIS. 
The  case  represented  by  Fig.  42  was  submitted  to  the 
staff  connected  with  a  large  children's  clinic,  for  an  opinion. 
Each  physician  was  permitted  to  separately  elicit  the  his- 
tory and  to  examine  the  patient.  The  following  diagnoses 
were  received :  sarcoma,  rheumatism,  osteomyelitis,  perios- 
titis, tuberculosis,  rickets,  and  ununited  fracture.  Sarcoma 
may  be  eliminated  by  the  previous  history,  the  compara- 
tively sudden  appearance  of  the  tumor,  the  condition  of 
the  gums,  other  evidences  of  hemorrhagic  extravasation, 
and  the  rapid  recovery  upon  the  institution  of  proper 
dietetic  management.  Rheumatism  is  distinguished  by 
polyarticular  involvement,  acid  sweats,  characteristic  tem- 
perature, and  its  comparative  rarity  during  infancy.  The 
joints  in  scurvy  are  rarely  involved.  This  is  the  most  com- 
mon mistake  in  reference  to  the  diagnosis  of  scurvy.  It  is 
so  common  that  it  is  of  sufficient  importance  to  repeat  that 
the  very  fact  of  making  a  diagnosis  of  rheumatism  in  an 
infant  is  in  itself  sufficient  evidence  to  arouse  suspicion  of 
the  presence  of  scurvy.  Osteomyelitis  and  periostitis  may 
cause  some  confusion.  They  more  commonly  attack  the 
tibia.  There  may  be  a  history  of  trauma.  There  is  an 
absence  of  hemorrhages.  The  temperature  is  decidedly 
septic  and  the  skin  over  the  bone  is  reddened  and  inflamed. 
Leucocytosis  is  usually  over  20,000  and  is  distinguished 
by  an  increase  in  the  polymorphonuclear  cells.  Tuberculosis 
may  be  excluded  by  the  history,  the  longer  duration  of  the 
case,  the  presence  of  tuberculosis  elsewhere  in  the  body,  the 
absence  of  hemorrhages,  and  a  positive  Moro  or  von 
Pirquet  reaction.  Rickets  may  accompany  scurvy  as  in  the 
case  here  illustrated.  Pure  rickets,  however,  presents  a 
different  history  and  is  unassociated  with  a  hemorrhagic 


DIAGNOSIS  AND  DIFFERENTIAL  DIAGNOSIS.        229 

tendency.  In  rickets  the  bony  enlargements  affect  the 
epiphysis  and  are  distinctly  localized.  The  other  bone 
changes  usually  take  the  form  of  curvatures  and  are  brought 


Fig.  43. — Same  child  after  recovery  from  scurvy.  Note  absence  of 
swelling  of  extremities.  .  Child  still  undernourished ;  still  shows  some 
evidence  of  rickets  (square  head,  beaded  ribs,  relaxed  belly).  Ex- 
pression, however,  is  natural. 

t 

about  by  the  action  of  gravity  and  muscular  traction  and 
atmospheric  pressure.  Ununited  fracture  usually  gives  a 
history  of  trauma  and,  while  some  resemblance  between  it 


230  SCURVY. 

and  scurvy  may  exist,  the  mistake  should  not  occur  if  the 
latter  be  borne  in  mind.  The  distinguishing:  features  of 
epiphysitis  have  been  indicated,  except  that  epiphysitis  most 
often  involves  the  lower  forearm.  Of  especial  importance 
is  the  history  of  a  perverted  dietary  and  the  early  develop- 
ment of  anemia,  peevishness,  crying  when  handled  or 
bathed,  and  a  very  evident  desire  to  lie  in  bed  undisturbed. 

PROGNOSIS  AND  COMPLICATIONS. 

When  detected  sufficiently  early,  before  the  infant's 
strength  is  exhausted,  the  outlook  is  good.  Recovery  is 
prompt  and  permanent.  A  marked  change  is  noted  usually 
in  four  or  five  days,  although  cases  which  are  recognized 
late  may  extend  over  four  or  five  weeks.  If  the  case  has 
progressed  too  far,  death  from  asthenia  occurs.  Cerebral 
and  visceral  hemorrhages,  secondary  infection,  epiphyseal 
separation,  occur  in  neglected  cases.  Those  cases  which 
present  a  delicate  digestive  apparatus  or  food  idiosyncrasies 
or  are  complicated  by  severe  rickets,  end  slowly  in  recovery, 
or  may  terminate  fatally. 

TREATMENT. 

This  is  purely  dietetic. 

Prophylaxis. — Breast  feeding  up  to  9  months  or  a  year 
and  not  longer.  If  the  child  is  artificially  reared,  prolonged 
boiling  of  the  food  is  not  permissible  without  the  addition 
of  other  food.  Fresh  fruit-juices, — orange,  plum,  grape, — 
as  well  as  fresh  beef -juice,  are  to  be  fed  regularly  to  the 
infant  between  milk  feedings.  Patented  foods,  especially 
those  that  require  boiling,  are  to  be  eschewed  as  a  permanent 
diet. 


TREATMENT.  231 

Treatment  of  Attack. — The  best  possible  hygienic  sur- 
roundings should  be  secured.  In  the  beginning  the  infant 
should  not  be  unduly  disturbed  by  too  frequent  attempts 
to  bathe  it  or  to  change  its  clothes.  Scorbutic  swellings,  no 
matter  how  muchi  they  may  resemble  inflammatory  exu- 
dates,  are  under  no  circumstances  to  be  incised.  Such  a 
procedure  may  cause  fatal  hemorrhage  or  secondary  infec- 
tion. Where  it  is  impossible  for  the  mother  to  suckle  her 
babe,  wet-nursing,  if  feasible,  should  be  secured.  In  the 
absence  of  either  of  these  sources  of  food,  raw  cows'  milk 
adapted  to  the  child's  age  and  digestive  capacity,  is  the 
remedy  that  will  bring  about  a  cure.  Fruit-juices — prefer- 
ably orange-juice  from  2  to  3  ounces  a  day — must  be  ad- 
ministered, but  not  just  before  or  after  a  milk  feeding.  If 
necessary  it  may  be  sweetened,  or  if  not  available  the  juice 
of  apples,  plums,  or  grapes  may  be  substituted,  although 
orange-juice  is  preferable.  From  one-half  to  one  whole, 
mealy,  baked  or  boiled  potato,  given  plain  or  creamed  with 
milk,  possesses  an  excellent  antiscorbutic  effect.  Fresh 
beef-juice  (not  beef-tea  or  beef -extracts),  fluidounce  ^  to 
fluidounce  i,  a  day,  must  also  be  given.  Gelatin  may  also  be 
of  some  assistance. 

There  is  no  special  medicinal  treatment,  except  the  use 
of  tonics  to  combat  the  anemia.  The  hypodermic  adminis- 
tration of  the  citrate  of  iron  alone,  or  with  sodium  cacody- 
late,  admirably  fulfills  this  indication. 


CHAPTER  VII. 

VOMITING. 

THIS  condition  is  not  a  distinct  disease  entity.  On  the 
contrary,  my  main  purpose  shall  be  to  emphasize  its  impor- 
tance as  a  symptom.  Regarded  as  such,  it  becomes  neces- 
sary to  study  in  detail  the  etiologic  factors  concerned,  so 
that  an  intelligent  therapy  may  be  arranged.  It  follows 
therefore,  too,  that  each  case  must  be  individually  consid- 
ered. The  causes  of  vomiting  differ  somewhat  in  infancy, 
i.e.,  under  2  years,  from  those  occurring  in  early  childhood 
(after  2  years) ;  hence  a  more  or  less  elastic  subdivision 
may  be  formed  as  follows:  No.  i,  Vomiting  of  Infancy; 
No.  2,  Vomiting  of  Early  Childhood. 

VOMITING   OF   INFANCY. 

In  the  early  days  of  life,  up  to  the  age  of  6  months 
the  stomach  is  almost  entirely  covered  by  the  large  left  lobe 
of  the  liver.  When  the  stomach  is  filled  the  liver,  there- 
fore, interferes  with  the  rapid  emptying  of  the  gastric  con- 
tents through  the  pylorus  and,  by  pressure,  causes  the 
stomach  to  assume  a  more  vertical  position  than  when 
empty.  This,  together  with  the  undeveloped  valve  action 
of  the  cardiac  end,  permits  and  explains  the  early  re- 
gurgitation  of  food  at  this  time  of  life.  This  type  of 
vomiting  or,  better  called,  regurgitation,  occurring  imme- 
diately after  feeding,  may  be  regarded  almost  as  physio- 
logic, or  simply  as  the  overflowing  of  an  overfilled  reser- 
voir. In  some  cases  it  does  no  harm.  In  others,  should  it 
become  excessive,  it  decidedly  interferes  with  the  nutrition 
(232) 


VOMITING   OF  INFANCY.  233 

of  the  infant.  It  becomes  less  frequent  after  6  months,  as 
there  is,  after  this  period,  a  decided  increase  in  the  greater 
curvature  and  the  cardia,  together  with  the  development  of 
the  valve-like  action  at  the  cardiac  orifice.  Nor  does  the 
liver  cover  the  entire  organ. 

The  prevention  and  cure  of  this  variety  of  vomiting  can 
often  be  readily  accomplished  by  the  forming  of  regular 
habits  which  permit  of  a  correct  feeding  interval,  and  of  the 
administration  of  the  proper  amount  of  food  at  each  feeding. 
The  infant  must  not  be  picked  up  immediately  after  its 
meal,  and  it  must  be  laid  upon  its  right  side  so  that  the 
rapid  emptying  of  the  stomach  may  be  favored. 

The  pernicious  habits  of  irregular  feeding  and  of  over- 
feeding are  responsible  for  the  vast  majority  of  cases  of 
functional  vomiting  occurring  under  I  year  in  both  the 
breast-  and  in  the  bottle-fed.  In  making  this  statement  my 
personal  experience  is  not  in  accord  with  certain  teachers 
who  advocate  the  giving  of  as  much  food  to  an  infant  as  it 
wants,  and  as  often  as  it  wants  it.  Physicians  are  led  into 
this  error  by  regarding  crying  as  a  sure  sign  of  hunger. 
They  forget  that  the  baby  may  be  thirsty  of  otherwise  un- 
comfortable. 

The  giving  of  food,  on  account  of  its  warmth  or  pleas- 
ant taste,  may  momentarily  relieve  colic  or  distract  the 
baby's  attention  and  thereby  quiet  it.  The  pain  returns 
with  increased  vigor  and  is  again  assuaged  in  a  similar 
manner.  Simple  regurgitation  of  food  now  becomes  a  con- 
dition of  true  vomiting,  dependent  upon  fermentation  and 
dilatation,  if  not  upon  actual  gastritis.  The  best  argument 
that  an  infant  should  not  be  permitted  to  nurse  until  it 
voluntarily  stops,  is  furnished  by  anatomic  and  physiologic 
facts.  The  capacity  of  an  infant's  stomach  at  birth  is, 


234  VOMITING. 

approximately,  an  ounce  and,  according  to  the  figures  offered 
by  Cotton,  this  develops  as  follows: — 

End  of  first  month   2^  oz. 

End  of  second  month   • 3^2  oz. 

End  of  third  month  4^4  oz. 

End  of  fourth  month   5      oz. 

End  of  fifth  month    S1/.  oz. 

End  of  twelfth  month 81/-  oz. 

My  own  experience,  based  upon  actual  weighing  experi- 
ments, with  quite  a  large  number  of  breast-fed  babies,  be- 
fore and  immediately  after  feeding,  as  to  the  stomach's 
ability  to  hold  the  amounts  at  the  various  ages  indicated, 
would  place  the  figures  even  somewhat  lower.  However, 
taking  these  as  a  guide,  one  cannot  help  but  see  how 
ridiculously  foolish  it  is,  not  to  say  dangerous,  to  offer 
to  an  infant  under  I  month  of  age,  from  4  to  5  ounces  of 
food  at  a  nursing,  as  I  frequently  see  done  by  men  of  large 
patronage  and  experience.  This  practice  is  pernicious  and, 
when  it  induces  vomiting,  the  condition  is  most  difficult  to 
control,  even  after  the  quantity  is  reduced.  The  reasons 
for  this  have  been  mentioned,  namely,  dilatation  and  atony, 
if  not  true  gastritis.  A  safe  rule,  perhaps,  would  be  to 
regulate  the  quantity  fed  in  such  a  manner  that  it  repre- 
sents in\  ounces  the  child's  age  in  months  up  to1  about  6 
months.  After  this  the  rate  of  progression  should  be 
slower  (Chapter  II). 

What  is  true  of  the  quantity  fed  as  a  cause  for  vomiting 
is  likewise  true  of  the  interval  of  feeding.  No  new  food 
must  be  put  into  the  stomach  until  the  organ  has  emptied 
itself,  regained  its  tone,  and  rested.  Feeding  too  fre- 
quently is  as  pernicious  as  too  much  food  at  a  feeding,  and 
amounts  to  the  same  thing,  and  is  productive  of  the  same 
ill-effects.  It  retards  gastric  digestion,  impedes  gastric 


VOMITING   OF  INFANCY.  235 

motility,  and  hence  produces  fermentation,  colic,  vomiting, 
and  other  symptoms  upon  which  depend,  in  turn,  the  early 
evidences  of  malnutrition  and  essential  marasmus.  It  is  a 
notorious  fact,  readily  confirmed  by  anyone  who  has  had  a 
large  experience  in  the  management  of  these  wasted  babies, 
that  the  vast  majority  of  them  present  a  history  in  which 
overfeeding  or  too  frequent  feeding,  or  both,  are  the  de- 
termining etiologic  factors.  While  what  an  infant  receives 
as  food  is  important,  it  is  just  as  important  how  if  gets  it 
and  when  it  gets  it.  The  caprices  of  its  appetite  or  the 
whims  of  its  caretaker  are  poor  judges  of  what  is  necessary 
to  supply  its  nutritional  demands. 

The  prevention  and  cure  of  this  type  of  vomiting  is 
self-evident,  viz.,  the  proper  regulation  of  the  food  as  to 
the  quantity  and  the  interval  of  feeding.  The  first  has 
already  been  discussed.  As  to  the  second,  no  fixed  rule  will 
apply  to  each  infant.  The  individual  must  be  studied  to 
learn  his  peculiarities,  but  when  once  the  interval  has  been 
determined  it  must  be  adhered  to  strictly. 

If  the  infant  is  not  to  vomit  after  feeding,  it  is  not  to 
be  picked  up  or  shaken,  but  after  its  meal  it  must  be  per- 
mitted tot  lie  quietly  undisturbed,  preferably  on  its  right 
side.  The  time  spent  at  the  breast  should  vary  from  ten  to 
thirty  minutes,  dependent  upon  the  age  of  the  infant  and 
the  interval  of  feeding,  but  under  no  circumstances  should 
the  meal  be  interrupted  to  be  resumed  again  later.  These 
rules  apply  to  the  bottle-fed,  as  well  as  to  the  breast-fed 
baby. 

The  causes  of  vomiting  thus  far  detailed  apply  to  both 
classes  of  infants.  There  are,  however,  certain  conditions 
which,  while  applicable  to  all  infants,  apply  with  more 
emphasis  to  the  breast-  or  to  the  bottle-  fed,  as  the  case 


236  VOMITING. 

might  be.  Thus  we  have  the  importance  of  the  composi- 
tion of  the  food  applying  with  greater  force  to  the  bottle 
baby,  although  its  significance  cannot  be  ignored  entirely 
when  dealing  with  breast-fed  children.  The  ingredients  of 
the  food  most  commonly  at  fault  are  the  fat  and  less  often 
the  sugar,  and  to  those  accustomed  to  dealing  with  these 
cases  the  clinical  symptoms  are  significant  and  frequently 
permit  of  a  correct  interpretation  (Chapters  II  and  IV). 

The  vomitus  due  to  excessive  fat  is  distinctly  sour  and 
acid,  smelling  like  rancid  butter.  It  contains  lumps;  of 
coagulated  calcium  casein,  holding  within  their  meshes  the 
fermenting  fat  which  is  soluble  in  ether  and  reacts  charac- 
teristically with  osmic  acid,  and  to  Sudan  III.  These  pieces 
of  curd  are  large  or  small  and  have  a  yellowish  appearance. 
The  time  of  vomiting  in  this  condition  is  important,  occur- 
ring from  one  hour  to  one  and  a  half  hours  after  feeding, 
i.e.,  after  fermentation  has  occurred.  The  vomiting  due  to 
excessive  feeding  or  to  too  frequent  feeding,  on  the  other 
hand,  occurs  immediately  after  a  meal,  the  vomited  matter 
being  as  a  rule,  in  the  beginning,  unchanged  and  frequently 
uncoagulated.  With  vomiting  due  to  fat  intolerance  there 
are  characteristic  bowel  symptoms  as  well  which  have  been 
discussed  in  Chapters  II  and  IV,  pages  in  and  179. 

The  remedy,  if  in  the  breast-fed,  is  to  attempt  the  re- 
duction of  the  fat  percentage  by  modifying  the  mother's 
milk.  This  is,  as  a  rule,  more  readily  accomplished  than  to 
increase  the  percentage  where  the  fat  is  too  low.  The  free 
drinking  of  water  by  the  mother,  the  partial  or  complete 
exclusion  of  milk,  soup,  malt  liquors  and  meat  from  the 
dietary,  increase  in  exercise,  and  the  occasional  use  of  laxa- 
tives are  measures  well  calculated  to  accomplish  the  result 
desired.  In  rare  instances  the  infant's  stomach  should  be 


VOMITING   OF   INFANCY.  237 

washed  once  or  twice.  This  applies  with  greater  force  to 
the  bottle-fed.  Each  nursing  should  be  preceded  by  an 
ounce  or  two  of  some  cereal-water,  preferably  made  from 
barley  or  wheat.  Occasionally  these  cases  progress  more 
rapidly  if  the  meal  is  followed  by  a  grain  or  two1  of  extract 
of  pancreatin,  used  simply  as  a  temporary  means  until  the 
fat  reduction  is  accomplished.  Where  it  is  impossible  to 
reduce  the  fat  the  breast  milk  may  be  withdrawn  and 
diluted  with  a  cereal-water  and  fed  from  a  bottle,  or  the 
first  milk  may  be  expressed  or  pumped  from  the  breast,  and 
the  infant  allowed  tot  suck  "middle"  milk  or  "last"  milk  so 
called.  Very  rarely  the  breast  milk  may  be  withdrawn  and 
pancreatized.  Any  of  these  maneuvers,  alone  or  in  combina- 
tion, will  usually  suffice  to  accomplish  the  desired  result  in 
breast-fed  babies. 

In  bottle  babies,  as  a  rule,  the  problem  is  simpler.  Here, 
following  the  stomach  washing,  the  infant  is  fed  for  twenty- 
four  hours  upon  some  cereal-water  or  weak  tea  slightly 
sweetened  with  sugar  or  with  saccharin  (gr.  j  to  a  quart). 
The  physician  may  then,  by  increasing  the  dilution  of  whole 
milk,  so  adjust  the  fat  content  as  to  suit  the  infant's  digestive 
capacity.  This  failing,  resort  may  be  had  to  pancreatiza- 
tion  or  to  the  temporary  feeding  of  whey,  which  is  weak  in 
fat.  In  rare  instances,  where  vomiting  continues  and  the 
infant  appears  to  be  intolerant  of  all  fat,  we  may  employ, 
with  success,  modifications  of  skimmed  milk,  eiweissmilch, 
buttermilk,  or  condensed  milk. 

Sugar  is  rarely  a  cause  of  vomiting,  but  may  be.  It 
practically  never  is  in  the  breast-fed.  When  a  source  of 
trouble,  it  is  not  uncommonly  associated  with  a  watery 
diarrhea.  The  vomitus  is  watery,  sour,  and  hot,  and  occurs 
late  after  feeding  and  may  cause  crying,  as  the  regurgitated 


238  VOMITING. 

material  may  produce  a  burning  pain  in  the  esophagus. 
The  remedies  consist  of  an  initial  purge,  rarely  a  stomach 
washing,  less  often  a  colonic  flushing,  and  the  reduction  in 
the  amount  of  sugar.  Buttermilk  and  eiweissmilch,  which 
are  sugar-poor,  may  be  of  service. 

The  protein  rarely  causes  vomiting,  unless  given  in  ex- 
cessively large  amounts,  when  the  resulting  curd  acts  as  a 
foreign  body  and  is  expelled.  Sodium  citrate  added  to  the 
formula  in  the  strength  of  i  to  2  grains  for  every  ounce  of 
milk  and  cream  in  the  mixture  has,  in  my  experience,  been 
of  considerable  aid  in  overcoming  vomiting  due  to  tough 
curd  formation  in  the  stomach. 

As  a  cause  for  vomiting  congenital  pyloric  obstruction 
is  too  rarely  recognized.  I  have  elsewhere  called  attention 
to  this  fact,  but  wish  here  to  offer  what  follows,  as  a  safe 
guide,  with  the  hope  that  others  will  adopt  it  as  a  means 
for  diagnosis  and  for  saving  the  lives  of  many  infants 
whose  condition  becomes  hopeless  before  it  is  recognized, 
and  whose  deaths  are  largely  ascribed  to  other  causes,  viz., 
that  all  cases  of  vomiting,  beginning  at  birth  or  shortly 
thereafter  and  continuing  in  spite  of  a  reasonable  amount  of 
food  manipulation,  especially  in  breast-fed  infants,  or  in 
artificially  fed  ones  as  well,  are  to  be  regarded  as  cases  of 
pyloric  obstruction,  until  it  can  be  proved  that  they  are  not. 

In  direct  opposition  to  this  fatal  type  of  persistent  vomit- 
ing should  be  mentioned  a  type  of  persistent  vomiting  or 
spitting  up,  of  an  entirely  benign  nature.  This  occurs  in 
either  perfectly  healthy  breast  or  bottle  babies  who  per- 
sistently and  steadily  continue  to  thrive  and  to  gain  in 
weight.  An  adequate  explanation  for  its  occurrence  is 
difficult  or  almost  impossible  of  determination,  and  no 
treatment  seems  to  be  of  avail.  Dietetic  manipulations  are 


VOMITING   OF  INFANCY.  239 

without  effect  and  usually  do  harm  by  interfering  with  the 
infant's  nutrition.  The  weight  either  remains  stationary  or  a 
slight  loss  is  recorded.  It  continues  until  it  is  spontaneously 
arrested  as  stated,-  and  not  infrequently  occurs  in  perfectly 
healthy  breast  babies,  where  the  breast  milk,  by  repeated 
analysis,  is  found  to  be  perfectly  normal.  While  a  cause 
for  it  undoubtedly  exists,  the  most  plausible  explanation  is 
a  vicious  habit,  which,  perhaps,  has  its  origin  in  faulty 
hygiene.  The  condition  may  be  cautiously  diagnosed  and  a 
good  prognosis  given  only  when  all  other  possible  causes 
have  been  entirely  excluded. 

A  type  of  vomiting  closely  akin  to  this  is  that  due 
directly  to  nervous  irritability  or  nerve  exhaustion  or  even, 
perhaps,  to  a  nervous  habit  or  tic  affecting  the  gastric 
musculature.  While  the  exact  nature  of  the  mechanism  of 
the  nervous  involvement  is  not  easy  of  detection,  clinical 
experience  and  close  observation  will  sooner  or  later  unmask 
the  true  nature  of  the  condition  as  to  its  nervous  origin. 
These  babies  fuss  while  nursing  the  breast  or  sucking  the 
bottle — or  if  this  does  not  occur,  as  soon  as  the  feeding  is 
finished,  they  begin  to  fret  or  to  squirm  and  wriggle  and 
distort  their  features  until  vomiting  occurs,  either  force- 
fully or  not  so.  The  vomiting  may  be  preceded  by  chewing 
motions.  The  nutrition  does  not  always  suffer  seriously 
unless  the  food  is  changed  too  often,  especially  as  is  com- 
monly the  case  if  the  food  be  weakened  too  much.  The 
reason  why  they  maintain  a  stationary  weight  or  lose  but 
slowly  is  because  many  of  these  babies  will  nurse  well  at 
night  and  retain  their  nourishment.  This  is  an  important 
point  in  making  the  diagnosis,  but  is  often  not  elicited 
except  by  accident  or  only  after  careful  inquiry.  I  have 
met  many  such  cases  after  they  have  gone  the  rounds  of 


240  VOMITING. 

many  physicians  and  have  run  the  gamut  of  an  innumerable 
variety  of  milk  formulas  and  patented  foods.  These  infants 
resemble  the  adult  neurasthenic  whose  distressing  symp- 
toms are  commonly  relieved  after  sunset — a  strong  point 
always  in  the  diagnosis  of  nerve  exhaustion.  Some  of 
these  babies  will  only  nurse  well  and  retain  their  nutriment 
if  it  is  given  to  them  during  sleep,  they  positively  refusing 
to  take  it  while  awake,  immediately  rejecting  that  which 
was  forced  upon  them. 

The  diagnosis  of  nervous  vomiting  must,  especially  in 
infants,  be  made  with  extreme  caution  and  only  after  all 
other  possible  factors  have  been  eliminated.  In  considering 
the  treatment  of  these  babies  the  most  important  thing  to 
learn  not  to  do  is  to  change  the  food  too  often.  Once  the 
diagnosis  is  made,  the  vomiting  must  be  ignored  as  far  as 
food  changes  are  concerned,  provided  the  stools  show  the 
digestion  to  be  normal.  One  or  two  stomach  washings 
with  soda  bicarbonate  solution  may  be  of  assistance,  but  must 
not  be  continued.  Paraf  Javal's  preparation  of  strontium 
bromid  ^lv-xv  may  be  administered  one-half  hour  before 
feeding,  four  times  a  day,  in  a  little  water.  As  the  age  and 
nutrition  demand  it,  the  strength  of  the  food  should  be 
slowly  increased,  in  quantity  as  well  as  quality.  Advantage 
should  be  taken  of  the  fact  that  these  babies  retain  their 
night  feeds  well  by  giving  them  nourishment  throughout 
the  night,  at  about  three-  or  four-  hour  intervals. 

Vomiting  is  a  symptom  of  summer  diarrhea.  This  is 
almost  entirely  confined  to  the  bottle-fed.  It  is  impossible 
to  enter  into  a  discussion  of  this  disease  at  this  time,  but  I 
wish  merely  to  refer  to  the  symptomatic  and  prognostic  im- 
portance of  vomiting.  Occurring  at  the  very  onset  of  the 
disease,  it  results  from  the  direct  irritation  of  the  gastric 


VOMITING   OF  INFANCY.  241 

niucosa,  and  is  benign  in  character,  in  that  the  system  is 
saved  the  absorption  of  a  large  amount  of  fermenting 
material  if  it  were  to  pass  through  the  gut.  Occurring  con- 
tinuously throughout  an  attack,  or  manifesting  itself  as  a 
late  feature,  it  is  ominous,  resulting  from  intense  toxemia 
and,  in  the  majority  of  instances,  foreshadows  a  fatal  out- 
come. Treatment  is  unsatisfactory.  Lavage  to  be  of  value 
must  give  speedy  results,  and  must  not  be  continued  too 
long  or  be  too  frequently  repeated.  A  valuable  procedure 
is  gavage.  Not  infrequently,  when  the  smallest  quantities 
of  food  are  expelled  when  fed  by  spoon  or  bottle,  they  will 
be  retained  if  given  by  the  stomach-tube.  However,  care 
and  skill  must  be  exercised  in  feeding  by  this  method 
(Chapter  XIII,  page  363).  The  gavage  should  follow  the 
lavage.  The  food,  on  the  other  hand,  may  be  administered 
through  the  nose  (Chapter  XIII,  page  361). 

Not  infrequently  all  food  by  mouth  must  be  suspended 
and  the  infant  sustained  by  small  nutrient  enemata  follow- 
ing colonic  lavage.  If  foods  are  given  by  the  mouth,  they 
must  be  of  the  mildest  kind  and  in  small  bulk,  concentrated 
but  non-irritating.  Cereal-waters  or  cereal-gruels,  egg- 
water,  condensed  milk  diluted  8  or  10  times  with  a  cereal- 
gruel,  whey  or  mutton-broth,  are  our  main  reliance.  Thirst 
may  be  allayed  by  hypodermocylsis  or  by  the  Murphy 
treatment.  I  have  seen  this  give  brilliant  results  in  des- 
perate cases.  Occasionally  hot  water  dropped  upon  the 
tongue  will  stop  vomiting.  Medicaments  are  of  little  value, 
perhaps  the  best  being  a  small  dose  of  bromid  of  strontium 
gr.  j-ij,  or  the  Paraf  Javal  preparation  just  mentioned. 

Vomiting  is  often  a  symptom  of  grave  abdominal  dis- 
ease. As  a  rule  it  here  depends  upon  peritoneal  irritation. 
Intussusception  is  the  most  frequent  condition  met  in  in- 

16 


242  VOMITING. 

fancy,  while  appendicitis,  peritonitis,  purulent  and  tuber- 
cular, occur  more  often  in  childhood.  The  character  of  the 
vomitus  will  not  infrequently  be  the  concluding-  point  in  the 
symptomatology  of  intussusception,  although  I  have  mis- 
taken a  fatal  purulent  peritonitis  occurring  in  an  infant  i 
week  old,  as  the  result  of  umbilical-cord  infection,  for  in- 
tussusception, on  account  of  constipation  and  fecal  vomit- 
ing. I  have  also  seen  a  small  retroperitoneal  sarcoma,  in  an 
infant  6  days  old,  produce  fecal  vomiting  and  bloody  stools. 
Vomiting  under  these  circumstances  has  no  special  treat- 
ment, its  main  importance  being  diagnostic  and  its  outcome 
depending  entirely  on  the  proper  surgical  treatment  of  the 
case. 

An  important  point  to  be  considered1  in  the  etiologic 
diagnosis  of  vomiting  in  infants  is  the  insidious  develop- 
ment of  hydrocephalus.  This  is  mentioned  to>  put  the  prac- 
titioner on  his  guard,  as  I  have  on  five  or  six  occasions  seen 
this  error  made  both  by  myself  and  others. 

VOMITING  IN  OLDER  CHILDREN. 

The  more  common  causes  for  vomiting  in  older  chil- 
dren are  the  acute  infectious  diseases,  pneumonia,  dietary 
indiscretions,  ivith  or  urithout  acute  gastritis,  acute  indiges- 
tion, poisons,  acute  abdominal  disease,  uremia,  brain  dis- 
ease, acidosis  (cyclic  vomiting,  so  called),  renex  causes,  and 
ocular  conditions.  Vomiting  is  an  important  initial  symp- 
tom of  scarlatina,  smallpox,  meningitis,  and  less  so  of 
measles.  It  may  replace  the  chill  of  pneumonia.  The 
direct  origin  of  vomiting  in  these  conditions,  with  the  ex- 
ception, perhaps,  of  meningitis,  is  toxic. 

By  far  the  vast  majority  of  cases  of  vomiting  in  young 
children  is  due  to  dietary  indiscretions.  Included  within 


VOMITING   IN   OLDER   CHILDREN.  243 

this  term  are  those  cases  due  to  chemical  or  food 
(ptomaines)  poisons,  or  medicines  ingested  by  accident  or 
otherwise.  These  cases  may  or  may  not  have  the  added 
element  of  gastritis  as  a  causative  factor. 

The  treatment  of  this  class  of  cases  may  be  embraced 
within  a  general  plan.  The  greatest  element  is  prevention. 
It  is  a  grave  mistake  not  to  supervise  the  food  of  a  young 
child  up  to  at  least  4  or  5  years,  and  even  after  this  vigilance 
should  not  be  relaxed.  Up  to  the  age  of  i  year,  in  most 
instances,  the  infant  should  receive  very  litle  besides  milk, 
and  that  preferably  maternal.  A  certain  amount  of  latitude 
can  perhaps  be  permited  in  this  direction,  depending  upon 
the  individual.  Many  physicians  are  in  the  habit  of  per- 
mitting a  certain  variety  of  dried  bread  called  zweiback,  at  a 
very  early  age.  I  have  never  seen  any  harm  therefrom,  but 
in  the  majority  of  American  children  I  feel  that  an  exclusive 
milk  diet  is  best,  at  least  up  to  9  or  10  months,  or  until  the 
infant  has  cut  several  teeth.  After  this  the  diet  should  be 
regulated  according  to  the  directions  given  under  Chapter 
III,  page  140. 

"Bring  up  a  child  in  the  way  it  shall  go  and  when  it  is 
old  it  will  not  depart  therefrom"  applies  to  diet  as  well  as 
to  morals,  and  an  adherence  to  a  simple  diet  of  wholesome 
foods,  with  absolute  regularity,  will  prevent  as  many  and 
more  cases  of  vomiting  and  indigestion  as  the  vicious  habit 
of  continuous  nibbling  and  overfeeding  of  improper  foods 
will  produce.  Frequently  children  are  brought  to  the 
physician  by  an  anxious  mother  with  the  tale  that  they  have 
no  appetite.  Careful  inquiry  will  invariably  elicit  the  his- 
tory that  the  day  is  occupied  by  one  continuous  meal  of 
small  quantities  of  sweets  and  indigestibles. 

The  active  treatment,  after  eliminating  the  cause  of  this 


244  VOMITING. 

condition,  consists  in  the  administration  of  an  emetic,  if  too 
much  time  has  not  elapsed  since  the  ingestion  of  the  sub- 
stance. If  the  stomach  has  not  been  actively  irritated  or 
inflamed,  lavage  should  be  practised.  This  is  a  very  diffi- 
cult procedure  in  young  children  and  should  only  be 
employed  if  urgent.  Following  this  a  purgative,  preferably 
iced  castor  oil,  or  if  this  is  not  tolerated,  calomel,  triturated 
well  with  sugar  of  milk,  should,  in  small  dose,  be  placed 
dry  upon  the  tongue.  Food  should  be  omitted  for  twenty- 
four  hours  and,  when  resumed,  should  be  of  the  mildest 
kind  and  given  often,  but  in  small  quantities.  Ice  by 
mouth  and  a  mustard  paste  upon  the  epigastrium  may  be 
of  service,  while,  of  medicaments,  cocaine  gr.  1/30,  bismuth 
gr.  x,  and  strontium  bromide  gr.  iij  are  the  best. 

In  acute  abdominal  disease,  especially  in  appendicitis 
and  in  peritonitis,  as  mentioned  before,  the  interest  attached 
to  vomiting  is  purely  academic  and  diagnostic.  In1  peri- 
tonitis the  vomitus  may  become  fecal  in  rare  instances  and 
indicates  a  fatal  outcome.  Rarely  these  cases  are  benefited 
by  extensive  lavage. 

The  insidious  onset  of  nephritis  and  uremia  is  often 
announced  by  an  unexpected  attack  of  nausea  and  vomiting. 
This  is  especially  true  when  occurring  during  the  third  or 
fourth  week  of  an  attack  of  scarlet  fever,  and  such  an 
occurrence  should  always  lead  to  a  urinary  analysis.  In 
this  disease,  therefore,  vomiting  becomes  a  symptom  of 
much  diagnostic  import.  Its  treatment  consists  in  the 
treatment  of  the  underlying  cause  and  is  entirely  elimina- 
tive,  this  being  accomplished  by  diaphoresis,  diuresis,  and 
catharsis. 

Vomiting  when  associated  with  or  rather  due  to  brain 
disease,  especially  tumor,  abscess,  meningitis,  less  often 


VOMITING   IN    OLDER   CHILDREN.  245 

hydrocephalus,  is  also  of  diagnostic  importance.  It  is  pro- 
jectile in  character  and  occurs  without  nausea.  There  is 
no  special  treatment. 

Of  greater  interest,  perhaps,  than  all  these,  in  that  it  is 
peculiarly  a  condition  of  childhood,  is  periodic  or  so-called 
cyclic  vomiting.  Children,  apparently  otherwise  well,  but 
of  delicate  mold,  the  former  subjects  of  scurvy,  marasmus 
or  rickets  perhaps,  without  any  apparent  cause,  certainly 
without  any  indiscretion  in  diet,  are  seized  with  severe 
attacks  of  vomiting.  First  the  stomach  contents  are  ejected 
and  then,  with  severe  straining  and  retching,  a  large 
quantity  of  bile-stained  material  is  thrown  off.  There  may 
.or  may  not  be  associated  fever.  Usually,  however,  the 
temperature  does  not  go  much  higher  than  100°  F. 
Jaundice  does  not  occur,  but  the  skin  becomes  muddy. 
Soon  the  attack  ceases  spontaneously  and  the  child  is  as 
well  as  ever  and  hungry,  and  remains  so  until  the  next 
attack  occurs  within  a  few  weeks.  Preceding  the  attacks 
the  child  becomes  languid,  pale,  loses  interest  in  its  play, 
and  has  dark  rings  under  its  eyes.  By  these  signs  the  care- 
taker can,  if  observant,  foretell  an  attack  by  twenty-four 
hours.  These  children  are  usually  anemic,  have  a  hemc*- 
globin  percentage  of  below  60,  and  are  sometimes  the  sub- 
jects of  purpura.  There  is  usually  a  slight  leucocytosis  up 
to  15,000.  The  etiology  of  this  interesting  condition  is 
obscure,  although  the  researches  of  Edsall  and  others  would 
point  to  an  acidosis  or  an  acidemia.  Many  of  these  cases 
present  a  highly  acid  urine  containing  large  amounts  of 
acetone,  diacetic  and  oxybutyric  acids. 

Treatment  is  unsatisfactory.  The  attack  is  self-limited 
and  remedial  measures  are  of  no  avail.  Between  attacks 
all  efforts  should  be  directed  toward  building  up  the  general 


246  VOMITING. 

strength,  improving  the  nutrition,  and  overcoming  the 
acidosis.  With  this  end  in  view  the  diet  should  contain 
starches  and  only  a  moderate  amount  of  protein.  Digest- 
ants  should  be  given  if  needed,  and  large  doses  of  sodium 
bicarbonate  over  a  long  period  of  time  are  regarded  as 
specific  by  Edsall  and  do  good  in  many  cases  as  a  preventive. 
Iron  citrate  or  sodium  cacodylate,  alone  or  combined,  and 
administered  hypodermically,  may  be  useful  in  combating 
anemia. . 

Reference  has  elsewhere  been  made  to  those  cases  of 
periodic  vomiting  which  are  not  due  to  acidosis,  but  which 
depend  upon  pylorospasm,  which  originally  developed  in 
infancy  and  which  has  not  entirely  recovered.  These  cases 
can  be  recognized  if  sought  and  especially  if  they  are 
studied  by  the  X-ray  (Chapter  XII). 


CHAPTER  VIII. 

CONSTIPATION. 

THIS  will  be  discussed  largely  from  the  standpoint  of 
treatment.  The  term  itself  is  more  or  lessl  comparative. 
The  movements  may  be  sufficiently  frequent  but  small  in 
bulk.  They  may  be  both  sufficiently  frequent  and  of  nor- 
mal bulk,  but  too  dry  in  consistency.  When  constipation  is 
complete  it  is  said  to  be  obstipation.  This  usually  depends 
upon  an  organic  basis.  An  intelligent  therapy  can  only  be 
arranged  after  considering  the  etiology  in  some  detail. 

ETIOLOGY. 

Two  factors  are  operative  more  or  less  in  nearly  every 
case  of  costiveness,  viz.,  diet  and  habit.  This  is  true  of 
infants  as  well  as  of  children.  Many  babies  are  made 
constipated  because  the  caretakers  do  not  give  them  an 
opportunity  to  evacuate  their  bowels  spontaneously.  This 
results  in  the  routine  administration  of  drastic  purgatives 
and  local  irritants,  as  suppositories  and  injections.  The 
bowels  shortly  cannot  empty  themselves  unless  they  are  so 
stimulated. 

A  diet  poor  in  sugar  and  fat  or  one  rich  in  protein  is 
particularly  harmful  in  this  respect.  Food  which  is  com- 
pletely digested  also  predisposes. 

Habit  is  especially  potent  in  older  children.  The  re- 
sponse to  nature's  call  is  delayed,  with  the  result  that  atony 
of  the  bowel  and  gaseous  distention  ensue.  In  cases  of 
rickets  in  which  the  involuntary  musculature  of  the  small 

(247) 


248  CONSTIPATION. 

intestines  is  decidedly  at  fault,  this  state  of  affairs  also 
exists. 

Constipation  in  the  Breast-fed. — A  great  many  mothers 
complain  that  their  babies  are  constipated.  I  find  in  most 
instances  that  these  women  do  not  give  their  children  a 
chance  to  move  their  bowels  naturally.  They  proceed  to 
administer  purgatives  and  injections  very  early,  usually  as 
soon  as  the  infant  exhibits  a  little  colic.  Most  of  these 
babies  consequently  do  become  constipated  from  such  treat- 
ment. If  the  mothers  are  reassured  and  are  instructed  to 
leave  the  babies  severely  alone,  the  fear  of  constipation 
speedily  passes,  as  soon  as  a  few  natural  evacuations  occur. 
Occasionally,  before  the  habit  is  fully  re-established,  use 
may  be  made  of  a  glycerin  suppository.  This  treatment 
must  not  be  continued  over  too  great  a  period  of  time,  for 
the  fear  of  establishing  the  habit.  It  is  only  employed  to 
help  out,  and  not  more  than  once  or  twice  a  week.  I  always 
advise  the  mother  to  allow  her  infant  to  go  thirty-six  hours 
before  she  attempts  to  bring  about  a  movement.  Usually 
before  this  period  of  time  has  elapsed,  a  spontaneous  evacu- 
ation will  have  taken  place. 

At  times  something  may  be  accomplished  by  a  milk 
analysis  and  by  attempting  through  the  mother's  diet  to  so 
influence  the  composition  of  her  milk  as  to  make  up  for  the 
visible  deficiency.  Thus,  the  amount  of  sugar,  fat,  and 
protein  may  be  varied  according  to  the  directions  already 
given  under  Chapter  I,  page  35.  While,  of  course,  quick 
results  cannot  be  expected  from  this  method  alone,  it  should 
always  be  pursued  as  a  very  important  adjuvant. 

It  is  often  of  service  to  administer  to  these  babies,  just 
before  feeding,  a  small  quantity  of  either  oatmeal  or 


ETIOLOGY.  •  249 

Granum  water.  Between  feeding,  under  any  circumstances, 
boiled  water  should  routinely  be  offered  to  all  breast  babies. 
Constipation  in  Artificially  Reared  Infants. — Constipa- 
tion is  not  uncommon  in  this  type  of  baby.  The  stools  are 
often  hard,  dry,  and  crumbly  (Plate  VIII),  and  are  expelled 
by  the  infant  with  great  straining.  Much  may  be  accom- 
plished by  dietetic  manipulation.  I  find  it  to  be  of  great 
service  to  change  the  diluent  of  the  milk  to  oatmeal-ivater. 
This  is  especially  effective  if  barley-water  or  a  wheat-flour 
gruel  has  been  employed  previously.  In  some  other  cases, 
where  the  formula  has  been  boiled,  feeding  it  raw  will  cor- 
rect the  trouble.  Hardly  to  be  recommended  as  a  routine 
procedure  and  yet  decidedly  effective,  is  the  feeding  of  the 
formula  cold  instead  of  warm.  In  other  cases  the  result  is 
favorably  influenced  by  increasing  the  amount  of  food  if 
this  has  been  found  to  be  unusually  small  in  bulk.  I  have 
noted  instances  wherein  the  concentration  of  the  food,  was 
insufficient,  i.e.,  the  amount  of  diluent  was  greater  than  the 
digestive  powers  of  the  infant  demanded,  and  entirely  too 
great  to  permit  a  sufficient  residue  to  provide  for  the  neces- 
sary normal  peristaltic  stimulus.  Thus  a  very  low  protein 
may  be  responsible  for  constipation.  On  the  other  hand  a 
very  high  percentage  of  protein,  especially  if  the  formula 
be  weak  in  fat  and  sugar  and  if  the  protein  be  highly  com- 
minuted, as  in  eiweissmilch  or  in  buttermilk,  or  if  the  pro- 
tein be  otherwise  influenced,  as  chemically  by  pancreatiza- 
tion  or  by  boiling,  may  cause  constipation  with  hard,  dry 
stools.  Unchanged  coagulable  cow-protein,  on  the  other 
hand,  when  fed  in  excessive  quantities,  may  cause  diarrhea 
on  account  of  the  irritant  effect  of  the  undigested  masses 
which  result.  In  these  instances  a  starchy  diluent,  as  bar- 
ley-water or  a  thin,  well-cooked  wheat-flour'  water,  is  of 


250  CONSTIPATION. 

service  in  checking-  the  diarrhea.  The  curd  may  also  be 
influenced  by  boiling,  pancreatization,  or  by  the  other 
methods  detailed  under  Protein  Intolerance  (Chapter  II, 
page  1 06). 

Infants  whose  formulas  are  especially  weak  in  fat  are 
commonly  constipated,  and  the  condition  can  be  favorably 
influenced  by  the  addition  of  cream  in  gradually  increasing 
amounts.  Care,  however,  must  be  exercised  not  to  exceed 
3^  to  4  per  cent,  (even  this  may  be  too  much  for  certain 
individuals),  otherwise  fat  intolerance  may  ensue,  with  the 
discouraging  evidences  of  weight  disturbance. 

Not  all  cases  are  benefited  by  increasing  the  fat.  Some 
are  made  worse,  especially  if  the  fat  be  split  up  into  fatty 
acids,  which  in  the  presence  of  lime-salts  causes  the  for- 
mation of  calcium-soap  stools,  which  are  constipated  (Plate 
VII).  Excessive  fat  may  cause  the  formation  of  a  greasy, 
foul-smelling,  constipated  stool  (Plate  VI).  These  stools 
contain  much  fatty  acid  and  often  present  the  odor  of 
overripe  cheese.  Lime-water  should  therefore,  unless  it  be 
used  for  a  special  indication,  as  hyperacidity,  rarely  enter 
into  the  composition  of  any  formula.  Personally  I  have 
practically  discarded  it  for  years,  and  have  not  felt  the 
necessity  of  employing  it  in  any  instance  except,  very  occa- 
sionally, in  cases  of  pyloric  obstruction.  These  cases  of 
constipation  due  to  an  excess  of  fat  are  benefited  by  diminish- 
ing the  fat  or  by  predigesting  it  (pancreatization). 

Constipation  in  the  bottle-fed  is  often  materially  im- 
proved by  increasing  the  amount  of  sugar  or  by  changing 
from  milk-sugar  to  cane-sugar  or,  still  better,  to  some  of  the 
malt  preparations,  as  Dextri-Maltose.  The  effects  of  low  fat 
and  of  low  protein,  even  though1  the  sugar  be  high,  are 
seen  in  babies  fed  upon  condensed  milk.  Many  of  them 


ETIOLOGY.  251 

suffer  from  constipation.  The  ideal  for  which  to  strive  is 
a  food  combination  in  which  all  the  elemnets  (fat,  protein, 
and  sugar)  are  reasonably  represented  and  in  which  no  one 
element  far  exceeds  the  others.  This  will  not  only  insure 
a  normal  state  of  the  intestinal  juices,  but  will  provide  a 
proper  nutritional  balance.  Elsewhere  I  have  stated  that 
almost  routinely  I  employ  cane-sugar  to  provide  extra  car- 
bohydrate. These  cases  of  constipation  constitute  one  of 
the  exceptions  in  which  I  make  use  of  one  of  the  malt 
preparations. 

A  diet  rich  in  starch  is  constipating.  In  fact,  this  is  not 
at  all  a  bad  way  in  which  to  favorably  influence  a  state  of 
diarrhea.  Many  of  the  patented  foods  are  constipating. 
The  milk  diluent  may  contain  too  much  starch.  I  have  seen 
constipation  result,  too,  from  the  use  of  buttermilk  into 
which  an  excess  of  wheat-flour  had  been  incorporated. 
Therefore  the  starch  must  be  reduced  and  the  diluent  made 
weaker.  In  some  instances  favorable  influences  are  noted 
where  the  diluent  is  dextrinized  after  the  method  of  Chapin, 
who  adds  some  diastatic  agent,  as  cereo  (glycerite  of  dias- 
tase) or  a  dram  or  two  of  one  of  the  many  malt  preparations 
upon  the  market. 

In  yet  other  infants,  good  results  are  obtained  by 
changing  the  diluent  completely  to  oatmeal-water.  This  is 
quite  laxative  in  its  effect  and  should  in  all  cases  be  tried. 
Many  babies  will  show  surprisingly  good  results  from  the 
use  of  this  simple  maneuver  by  itself. 

Fruit-juices  serve  an  admirable  purpose  in  the  bottle- 
fed,  not  only  on  account  of  their  antiscorbutic  effect,  but 
also  for  their  influence  upon  the  stools.  I  prefer  prune- 
juice  made  by  boiling  a  pound  of  prunes  in  a  quart  of  water 
without  sugar.  This  is  palatable,  antiscorbutic,  and  laxa- 


252  CONSTIPATION. 

tive.  Usually  from  2  to  3  teaspoon fuls  are  given  once  or 
twice  a  day  on  an  empty  stomach.  Other  juices,  as  of  the 
orange,  grape,  apple,  etc.,  may  be  employed. 

A  broth  made  from  vegetables  (Chapter  III,  page  146) 
is  useful  in  this  connection  and  may  be  given  ad  libitum. 

As  the  infant  grows  older  and  articles  other  than  milk 
are  added  to  the  diet,  other  things  being  equal,  the  tendency 
toward  constipation  is  often  materially  lessened.  Therefore, 
if  digestive  disturbances  are  absent  and  two  of  three  teeth 
have  been  erupted,  such  foods  as  oatmeal,  Graham  crackers, 
whole-wheat  bread,  and  tender  vegetables  may  prove  to  be 
eminently  useful.  Scraped  apple  may  also"  be  fed  in  tea- 
spoonful  doses  once  or  twice  daily. 

From  earliest  infancy  the  habit  of  regular  evacuations 
should  be  established.  The  infant's  buttocks  are  brought 
into  contact  with  a  small  chamber  at  definite  intervals  dur- 
ing the  day.  As  soon  as  the  baby  can  sit  up  it  should  be 
placed  in  a  chair  in  the  same  regular  way.  Later  the  habit 
of  having  a  daily  bowel  movement  should  be  made  an 
object  of  pride  on  the  part  of  the  child,  who  should  be  early 
taught  that  nothing  must  be  permitted  to  interfere  with  its 
response  to  nature's  demands.  Rewards,  if  necessary, 
should  be  offered  to  encourage  this,  and  mild  punishment 
inflicted  for  failure  to  obey. 

Older  Children. — Children  must  be  taught  to  crave 
wholesome  food.  It  is  just  as  easy  to  do  this  as  it  is  to 
allow  them  to  crave  those  foods  which  cause  digestive  and 
metabolic  disturbances.  Vegetables  in  abundance  are  not 
only  wholesome,  but  laxative  in  their  effects.  Stewed  and 
seasonable,  raw,  ripe  fruits  are  valuable  adjuncts,  but 
apples  must  be  scraped  or  very  thoroughly  chewed.  Well- 
cooked  coarse-grained  cereals,  especially  oatmeal,  are  valu- 


ETIOLOGY. 


253 


able.     Cereals  which   are  eaten  uncooked,   witW  milk  and 
sugar,    are    not    to   be   recommended.      An    abundance    of 


Fig.  44. — Constipation  due  to  dilated  colon  (Hirschsprung's  disease). 

butter  and  olive  oil,  if  they  cause  no  digestive  or  metabolic 
disturbances,  is  valuable. 


254  CONSTIPATION. 

Sweets  and  meats  are  constipating  and,  therefore,  they 
are  to  be  largely  curtailed.  I  have,  however,  met  instances 
wherein  diet  has  no  influence  at  all  in  relieving  the  condi- 
tion. One  patient,  a  little  boy,  recently  came  under  my 
observation,  who  consumed  seven  or  eight  apples  a  day 
without  any  effect  whatever  upon  his  stools.  Such  obstinate 
instances  require  the  use  of  drugs. 

MEDICINAL   TREATMENT. 

Where  dietary  measures  fail,  the  cause  of  the  consti- 
pation probably  depends  upon  functional  atony  or  upon 
anatomical  twists,  kinks  or  tortuosities  or  upon  congenital 
dilatation  of  the  colon  (Fig.  44).  In  addition  to  drugs 
mechanical  manipulation,  which  will  be  discussed  later,  is 
often  valuable.  To  rehearse  the  entire  list  of  purgatives 
would  be  time-consuming  and  useless.  I  shall  only  mention 
those  agents  which  have  been  useful  in  my  own  experience. 

I  have  obtained  very  encouraging  results  from  the  use 
of  some  form'  of  Russian  mineral  oil.  I  have  employed 
the  preparation  known  as  Interol  or  Rusol,  marketed  by 
Van  Horn  &  Sawtell,  or  Squibb' s  preparation,  or  Olo.  They 
all  act  the  same  and  one  is  as  good  as  the  other.  This  is 
true  as  well  of  the  American  mineral  oils  to  be  found  upon 
the  market.  These  oils  are  not  digested.  They  are  passed 
as  they  are  taken.  They  simply  lubricate  the  intestinal  wall 
and  cause  the  contents  to  slip  along  easily.  They  have  the 
great  advantage  of  being  tasteless.  They  are  administered 
from  a  spoon  or  placed  upon  a  little  water  which  the  child 
drinks  without  knowing  that  the  oil  has  been  added.  A 
very  small  amount  of  sugar  may  be  added  for  fastidious 
children,  and  the  dose  offered  to  them  as  "sugar-water." 
Infants  receive  from  i  to  2  fluidrams  once  or  twice  a  day,  on 


MEDICINAL  TREATMENT.  255 

an  empty  stomach.  Older  children  are  given  about  half  an 
ounce.  The  idea  is  to  administer  just  enough  to  secure  the 
proper  lubrication  which  will  insure  from  one  to  three 
movements  daily.  There  are  no  ill-effects.  Nor  is  there 
any  danger  of  establishing  a  habit.  The  only  inconve- 
nience noted  is  that  the  oil  will  leak  through  the  anus  and 
soil  the  clothing,  if  too  much  is  taken.  There  is  no  relaxing 
effect  upon  the  bowels,  and  of  all  permanent  agents  to  be 
employed  for  the  relief  of  constipation  I  firmly  believe  that 
one  or  another  of  these  preparations  is  by  far  the  best. 

Olive  Oil. — This  may  also  be  classed  as  one  of  the  valu- 
able semimedicinal  agents.  It  is  administered  per  oram  or 
per  rectum.  It  also  possesses  valuable  food  qualities,  and  is 
especially  useful  in  marantic  children  of  over  I  year  of  age. 
By  mouth  from  y2  fluidram  to  2  fluidrams  are  administered 
t.  i.  d.  after  meals.  It  is  often  more  readily  accepted  if 
given  with  grape-juice.  It  rarely  disturbs  the  digestion. 
It  must  then  be  given  per  rectum.  By  this  method  valuable 
results  are  commonly  obtained  if  the  remedy  is  properly 
administered  and  continued  over  a  sufficiently  long  time. 
Three  to  four  ounces  of  the  oil  are  deposited  high  into  the 
bowel  each  evening,  or  every  other  evening,  as  the1  infant  is 
put  to  bed  for  the  night.  A  soft-rubber  catheter  is  anointed 
and  gently  passed  into  the  bowel  for  a  distance  of  about 
eight  inches.  An  ordinary  small,  infant's,  hand  rectal 
syringe  is  now  filled  with  the  warm  oil,  and  the  hard- 
rubber  tip  is  connected  with  the  free  distal  end  of  the 
catheter,  and  the  contents  of  the  rubber  bulb  are  gently  com- 
pressed through  the  catheter  into  the  intestine.  One  or 
two  syringefuls  are  sufficient  (Chapter  XIII,  Fig.  56,  #). 
The  baby  is  diapered  and  usually,  the  next  morning,  there 
will  be  found  a  substantial  movement.  In  some  cases  this 


256  CONSTIPATION. 

occurs  immediately.  Gradually  the  frequency  of  these  in- 
jections may  be  lessened  if  the  movements  show  a  tendency 
toward  becoming  spontaneous,  as  they  frequently  do.  This 
treatment  is  also  valuable  in  older  children,  a  little  more  oil 
being  employed  as  well  as  a  slightly  thicker  catheter,  which 
may  be  inserted  about  ten  or  twelve  inches. 

Agar-agar  as  such,  or*  employed  as  Regulin  after  the 
method  of  Prof.  Dr.  Otto  Schmidt,  is  useful  in  some  cases. 
It  acts  by  absorbing  moisture  through  the  intestinal  mucosa 
and  thereby,  as  the  agar-agar  swells,  increases  not  only  the 
bulk  of  the  intestinal  contents,  but  makes  them  more  liquid. 
As  a  rule  I  prefer  the  ordinarily  powdered  agar-agar  as 
purchased  in  the  shops,  to  the  Regulin,  as  it  is  tasteless,  the 
latter  being  impregnated  with  cascara  sagrada,  which  makes 
it  bitter.  Either,  however,  is  administered  in  stewed  fruit 
or  cereal  in  I-  or  2-  dram  doses  once  or  twice  daily.  The 
results  are  not  always  satisfactory,  although  in  some  cases 
decided  benefit  is  experienced.  The  material  must  be 
mixed  with  the  food  during  the  child's  absence. 

Milk  of  Magnesia. — This  in  no  sense  cures  constipation. 
It  is,  however,  often  of  value  in  assisting,  especially  the 
bottle  baby,  across  a  troublesome  period.  Thus,  until  the 
proper-strength  formula  is  found,  many  infants  are  con- 
stipated. Often,  as  previously  stated,  the  condition  is 
remedied  by  changing  the  diluent  to  oatmeal-water.  Until 
this  is  done  or  has  a  chance  to  act,  15  to  20  to  30  or  more 
drops  of  Philip's  Milk  of  Magnesia  are  added  to  each 
bottle  or  to  every  other  bottle,  or,  perhaps,  but  once  or  twice 
a  day,  according  to  effect.  The  dosage,  both  in  amount 
and  in  frequency,  is  gradually  reduced  to  a  nicety — simply 
to  obtain  the  desired  result.  It  may  also  be  given  to  breast- 
fed babies.  It  is  finally  omitted. 


MEDICINAL  TREATMENT.        %  257 

Castor  Oil  is  mentioned  simply  to  impress  upon  the 
mind  of  the  student  that,  while  it  causes  looseness  of  the 
bowels,  it  must  never  be  considered  as  a  remedy  to  cure 
constipation.  When  indicated  it  is  one  of  the  best  remedies 
in  the  treatment  of  diarrhea.  Its  secondary  effect  is  relax- 
ing1 and  constipating.  It  is  simply  employed  to  effectively 
sweep  out  the  intestinal  tract.  To  this  it  owes  its  use  in 
diarrhea  and  also  in  cases  of  constipation  where  the  bowels 
have  not  moved  for  several  days  and  it  is  desired  to  cleanse 
the  intestines  and  to  relieve  acute  or  chronic  toxemia.  Its 
use  must  always  be  followed  by  tonic  laxatives,  of  which 

Cascara  Sagrada  is  the  best  example.  The  great  objec- 
tion to  it,  however,  is  its  taste.  This  may  be  more  or  less 
disguised  by  employing  the  aromatic  fluidextract  in  doses 
ranging1  from  15  to  45  drops  once  or  thrice  daily.  Or  it 
may  be  disguised  as  follows: — 

IJ  Liquid  extract  of  cascara  (B.  P.), 
Liquid  extract  of  liquorice  (B.  P.), 
Syrup  of  orange-peel, 
Chloroform-water    aa   n\xv. 

Or  as  follows : — 

Ifc  Sodium    sulphate    gr.  v. 

Liquid  extract  of  cascara  (B.  P.)  n^iiss. 

Glycerin    n\_v. 

Cinnamon-water    q.  s. 

I  have  seen  the  good  effect  of  both  of  these  formulas  in  the 
wards  and  in  the  out-patient  department  of  the  Hospital 
for  Sick  Children,  Great  Ormond  Street,  London.  The 
latter  prescription  is  slightly  more  stimulating  than  the 
former.  Through  experience  in  the  same  institution  I  have 
obtained  good  results  from  the  following  combination  of 
tonic  laxatives : — 

17 


258  CONSTIPATION. 

U  Tr.  nucis  vomicae  TT\.  ss. 

Tr.   zingiberis    niij. 

Tr.  hyoscyami   v\.v. 

Tr.  aloes  miv- 

Syrupi   sennae    nixv. 

Dill-water  (B.  P.)   q.  s. 

This  is  carminative  as  well  as  laxative.  A  small  quantity 
of  the  fluidextract  of  cascara  could  readily  be  added  with 
advantage. 

Phenolphthalein  is  a  useful  laxative  in  some  cases.  It  is 
found  upon  the  market  in  various  pleasant  combinations 
with  other  laxatives,  or  alone.  The  dose  varies  from  y2  to 
2  grains. 


Fig.  45. — Massage  balls  used  by  the  author  in  the  treatment 
of  constipation.     (Physician's  Supply  Co.,  of  Phila.) 

MECHANICAL    TREATMENT. 

No  case  of  constipation  is  properly  handled  unless 
mechanical  means  have  been  given  a  trial.  Of  these 
abdominal  massage  is  of  considerable  value.  In  my  own 
experience  this  is  best  accomplished  by  the  systematic  em- 
ployment of  a  massage  ball  (Fig.  45).  It  is  made  in  sizes 
Nos.  i,  2,  and  3.  They  consist  of  iron  covered  with  leather 
and  weigh,  respectively,  %  lb.,  1^2  Ibs.,  and  2  Ibs.  They 
resemble  baseballs.  They  are  made  for  me  by  the  Physi- 
cian's Supply  Company,  of  Philadelphia.  The  size  of  the 
ball  is  selected  according  to  the  age  and'  size  of  the  patient. 


SPONDYLOTHERAPY.  259 

No.  I  is  for  infants,  No.  2  is  for  children  from  il/2  to  2 
years  of  age,  and  No.  3  for  older  children.  Morning  and 
evening,  before  the  child  arises  and  before  it  retires,  the 
bladder  being  at  first  emptied,  the  ball  is  rolled  by  the  palm 
of  the  hand  in  a  circular  motion,  slight  pressure  being  used 
in  addition  to  the  weight  of  the  ball,  along  the  course  of  the 
colon,  up  the  right  side,  across  and  down  the  left.  This  is 
continued  for  from  ten  to  fifteen  minutes,  after  which  a  cir- 
cular motion  is  continued  for  five  minutes  over  the  center 
of  the  abdomen,  over  the  small  intestines.  I  find  that  many 
babies  are  benefited  to  no  small  degree.  The  treatment 
must  continue  for  two  or  three  months. 

SPONDYLOTHERAPY. 

Albert  Abrams,  of  San  Francisco,  recommends  that  in 
atomic  constipation,  the  most  common  variety,  concussion 
or  sinus oidilization  of  the  spines  o<f  the  first  three  lumbar 
vertebrae  be  practised  daily,  and  in  the  spastic  variety  the 
same  treatment  be  applied  to  the  spine  of  the  last  dorsal 
vertebra.  If  the  exact  nature  of  the  constipation  cannot  be 
determined,  alternate  concussion  of  these  areas  is  practised 
at  the  same  sitting.  Concussion  may  be  practised  by  placing 
a  piece  of  linoleum  about  %  -inch  thick  over  the  spine.  This 
is  then  struck  light  but  rapid  blows  with  an  ordinary  tack- 
hammer.  In  lieu  of  this  the  middle-finger  of  the  left  hand 
may  be  placed  upon  the  spine  and  struck  with  the  closed 
fist  of  the  right  hand,  which  acts  as  the  plexor  or  concussor. 


CHAPTER  IX. 

DIARRHEA. 

THIS  affection  will  be  considered  largely  in  its  relation 
to  the  suckling.  Therefore,  treatment  will  be '  discussed 
mainly  from  the  standpoint  of  the  breast-fed  and  the  baby 
fed  upon  cows'  milk. 

The  splitting  up  of  the  fat  of  the  food  sets  free  fatty 
acids.  These  normally  combine  with  the  alkaline  bases  of 
the  food  and  of  the  intestinal  mucus.  If  these  acids  be  in 
excess  they  not  only  irritate  the  intestinal  mucosa,  causing 
increased  peristalsis  and  an  increase  in  the  intestinal  mucus, 
but  also  cause  the  intestinal  contents  to  be  acid.  This  acidity 
favors  the  development  of  certain  bacteria  which  require 
an  acid  medium.  These  bring  about  destruction  of  the 
carbohydrate.  This  destruction  of  the  carbohydrate  is 
called  fermentation,  which  is  distinctly  an  acid-producing 
process,  and  this  still  further  favors  the  development  of  acid- 
producing  bacteria  and  the  development  of  diarrhea. 

Destruction  of  protein  is  called  decomposition  and 
results  in  the  formation  of  alkalies.  The  alkaline  medium 
favors  the  development  of  the  bacteria  of  decomposition. 

Thus,  the  interaction  between  certain  food  elements  and 
bacteria  results  in  either  fermentation  or  decomposition. 
In  health,  within  the  intestines,  each  process  is  proceeding 
simultaneously.  The  feces,  or  the  intestinal  contents,  will 
be  neutral,  or  slightly  alkaline  of  slightly  acid.  Neither 
alkalinity  nor  acidity  can  preponderate,  the  one  over  the 
other,  to  any  great  degree  without  resulting  in  a  disturbance 
(260) 


DIARRHEA.  261 

of  the  circulation  of  the  intestinal  mucosa.  This  results  in 
the  pouring  out  of  an  excess  of  mucus  and  in  an  increase  in 
the  peristaltic  action — diarrhea;  although  the  effects  of 
excessive  acidity  are  more  quickly  noted  than  are  those  of 
an  excess  of  alkalinity.  This,  and  also  the  fact  that  the 
presence  of  mucus  indicates  an  attempt  on  the  part  of 
nature  to  protect  the  lining  membrane  and  to  neutralize 
the  acid — for  intestinal  mucus  is  alkaline — have  an  impor- 
tant therapeutic  significance,  as  we  shall  see. 

From  the  preceding  it  follows  that  in  most  cases  of 
diarrhea  the  stools  are  acid  because  fermentation  is  more 
common  than  decomposition.  Even  in  the  presence  of  de- 
composition the  irritant  effects  of  the  alkaline  medium  is 
less.  The  continuous  outpouring  of  large  quantities  of 
mucus  causes  the  infant's  nutrition  to  become  seriously 
impaired  because  of  the  loss  of  great  quantities  of  water 
and  of  salts,  these  being  the  main  constituents  of  mucus. 

It  has  been  seen  how  the  reaction  of  the  intestinal  con- 
tents determines  the  nature  of  the  preponderating  variety 
of  bacteria,  and  how  this  reaction  depends  primarily  upon 
the  nature  of  the  food,  i.e.,  that  there  is  a  reciprocal  relas- 
tiomhip  existing  between  the  food  and  bacteria  and  that 
each  is  necessary  to  the  other  in  order  to  carry  on  the 
processes  of  intestinal  digestion.  It  is  also  understood  now 
that  the  character  of  the  food  readily  determines  the  nature 
of  the  bacteria. 

It  may,  therefore,  correctly  be  stated  that  the  nature 
of  the  food  which  is  given  to  an  infant  determines  largely 
the  presence  or  the  absence  of  diarrhea,  and  that  the  food 
assumes  at  once  the  dual  role  of  etiologic  factor  and  prime 
therapeutic  agent.  Clinically  this  has  been  proven  to  be  a 
fact,  and  most  cases  of  diarrhea  in  both  the  breast-  and  in 


262  DIARRHEA. 

the  bottle-  fed  will  yield,  if  not  neglected  too  long,  nicely  to 
dietetic  management  alone  and  without  the  use  of  drugs. 

SYMPTOMS. 

As  stated,  the  intestinal  contents  are  more  fluid,  usually 
more  acid  (sometimes  more  alkaline),  and  the  peristalsis  of 
the  gut  is  accentuated;  therefore  the  bowels  move  more 
frequently.  At  first  there  may  appear  but  very  little  change 
in  the  physical  appearance  of  the  discharges,  aside  from 
their  thinner  consistency.  Shortly,  however,  an  excess  of 
mucus  is  noted.  This  is,  as  a  rule,  very  stringy,  yet  withal 
intimately  mixed  with  the  stool.  The  latter  is  at  first 
yellow,  then  yellow  and  green,  and  finally  may  assume  a 
grass-green  appearance,  or  it  may  be  yellow-and-green 
mixed.  The  green  color  is  due  to  biliverdin,  an  oxidation 
product  of  bilirubin  (Plates  IV  and  V).  It  must  not  be 
forgotten  that  the  color  of  a  stool  must  be  noted  as  soon  as 
it  is  passed,  because  all  stools,  especially  those  of  sucklings, 
turn  green  an  hour  or  so  after  being  exposed  to  the  atmos- 
phere. If  the  process  continues  the  mucus  may  be  blood- 
streaked  or  a  fair  amount  of  blood  may  be  mixed  with  the 
stools  (Plate  X).  If  this  has  originated  high  up  in  the 
bowel  it  will  be  dark ;  if  low  down  it  will  appear  bright  and 
may  not  be  as  well  mixed.  As  the  case  progresses  the  fecal 
character  of  the  movements  may  be  lost  entirely,  it  consist- 
ing simply  of  a  colorless  discharge  of  water  or  mucus. 
These  stools  are  odorless  as  a  rule,  and  are  seen  commonly 
in  "summer  diarrhea"  (intoxication)  and  are  of  serious 
import. 

The  odor  of  the  stool  assists  in  determining  the  nature 
of  the  process  existing  within  the  intestine.  In  cases  of 
fermentation  the  odor  is  distinctly  sour  and  acid,  but  not 


SYMPTOMS.  263 

unpleasant.  In  cases  of  decomposition,  on  the  other  hand, 
the  reverse  is  true,  the  discharges  being  foul-smelling. 
The  reaction  may  be  readily  tested  with  litmus-paper. 
Further,  if  the  stools  are  intensely  acid  their  constant  exit 
from  the  anus  is  associated  with  severe  excoriation  of  the 
skin  about  the  buttocks  and  the  anal  region.  These  cases 
are  particularly  common  in  babies  who  cannot  digest  the 
sugar  of  their  mother's  milk,  and  in  bottle-fed  babies  who 
are  suffering  from  sugar  intolerance. 

In  cases  due  to  an  excess  of  fat,  nature  attempts  to  cor- 
rect the  acidity  by  causing  the  free  fatty  acids  to  combine 
with  the  alkaline  salts  which  are  contained  in  the  excess  of 
intestinal  mucus.  The  action  is  called  saponification,  and 
results  in  the  discharge  of  stools  containing  large  or  small, 
hard,  granular  masses  of  calcium  soap  (Plate  VII).  These 
masses  are  contained  in  a  liquid  matrix  of  mucus.  Their 
presence  in  constipation  has  also  been  noted  (Chapter 
VIII).  In  these  instances  all  the  fatty  acids  have  been 
neutralized  by  the  alkaline  (calcium)  bases  contained  in  the 
mucus — the  so-called  soap  stool  (Plate  VII).  These  cases 
also,  in  addition,  usually  exhibit  an  alkaline,  ammoniacal 
urine. 

The  stools  commonly  contain  white  particles  or  masses, 
as  well  as  mucus.  Much  time  and  discussion  have  been 
wasted  in  an  effort  to  determine  the  exact  nature  of  these. 
Are  they  constantly  protein  or  constantly  fat?  Latter-day 
pediatrists  contend  that  they  are  always  fat ;  that  undigested 
protein  never  is  pathologic.  With  this  view  I  cannot  be 
in  accord.  Unchanged  cows'  curd  (unchanged  chemically 
or  physically)  is  as  indigestible  today  as  it  was  twenty 
years  ago,  and  may  and  does  in  many  instances,  by  its 
directly  irritating  effect,  produce  diarrhea  (Chapter  II). 


264  DIARRHEA. 

Therefore  the  answer  fairly  made  is  that  these  white  masses 
may  be  either  protein  or  fat,  and  that  this  can  be  determined 
in  the  individual  case  by  the  proper  test  elsewhere 
described  (Chapter  II).  The  stools  appear  often,  under 
these  circumstances,  not  unlike  loosely  scrambled  eggs 
(Plate  IV). 

Constitutional  Features. —  No  infant  can  have  diarrhea 
without  suffering  as  to  its  nutrition.  These  babies  all  lose 
weight — more  or  less  according  to  the  severity  and  duration 
of  the  process.  Thus,  in  acutely  severe  cases  the  loss  of  a 
pound  or  two  in  twenty-four  hours  has  been  recorded.  In 
less  severe,  but  equally  obstinate  subacute  or  chronic,  cases 
this  amount  of  weight  may  be  lost  within  a  period  of  a 
week  or1  two.  The  loss  is  due  directly  to1  the  loss  of  water. 
The  tissues  become  dehydrated.  Fat  consists  largely  of 
water.  Therefore  the  plumpness  and  the  roundness  of  the 
babe  are  speedily  altered.  The  tissues  are  also  quickly 
demineralized.  Consequently,  nervous  irritability  may  in- 
dicate its  presence  by  a  positive  Chvostek  reaction  or 
increased  electrical  reactions  (vide  Spasmophilia,  Chapter 
X,  page  276). 

In  cases  of  dyspepsia  and  of  intoxication,  fever  develops. 
In  the  former  the  range  is  not  so  high — from  100°  to 
101°  F.  per  rectum,  while  in  the  latter  it  may  register  from 
104°  to  1 06°  F.  and  the  symptoms  of  intense  intoxication 
may  appear.  These  are:  collapse,  shallow  breathing, 
sunken  eyeballs,  sharp  features,  cold  nose,  coma,  ashen  hue 
about  the  nose  and  mouth,  albuminuria,  glycosuria,  rapid 
and  thready  pulse,  vomiting  at  times,  together  with  fre- 
quent watery  evacuations  and  a  tremendous  loss  in  weight 
(vide  Sugar  Intolerance,  Chapter  II,  page  113). 


SYMPTOMS.  265 

Diarrhea  or  Intestinal  Indigestion  in  the  Breast-fed. — 
Here  one  meets  a  colicky,  breast  baby,  suffering-  from 
gaseous  distention  and  diarrhea  with  yellow  or  greenish- 
yellow,  loose  stools  containing  stringy  mucus  and  finely 
chopped  up  white  particles  (Plate  V).  These  stools  have 
a  slightly  pungent,  acid,  not  unpleasant  odor.  These  babies 
have  excoriated  anal  regions  and  frequently  spit  up  after 
feeding.  In  many  the  skin  is  somewhat  irritated  or  there 
may  be  present  a  papular  eruption  all  over  the  body,  or  it 
may  be  confined  to  the  face.  These  infants  rest  poorly  and 
yet,  in  spite  of  their  discomforts  and  abdominal  objective 
features,  many  of  them  continue  to  gain  weight.  They  are  a 
source  of  worry  to  the  young  mother  and  of  endless  annoy- 
ance to  the  physican,  because  it  is  difficult  for  him  to 
appease  the  mother  with  the  statement  that  the  infant  is  all 
right  when  she  and  her  friends  think  that  it  is  all  wrong. 
These  cases,  in  my  judgment,  are  only  precarious  in  so  far 
that  they,  more  than  any  other,  are  speedily  taken  from  the 
breast  because  the  average  physician  does  not  understand 
how  to  treat  them,  because  the  mother  demands  that  some- 
thing must  be  done,  and  because  that  "something"  usually 
consists  in  removing  the  infant  from  the  breast  and  putting 
it  upon  some  indifferently  modified  formula,  instead  of  at- 
tempting to  treat  it  rationally  through  the  mother's  milk. 
From  this  point,  in  many  cases,  is  marked  the  beginning  of  a 
downward  course — the  feeding  of  many  and  varied  milk 
mixtures  and  patented  foods,  ending  in  further  digestive 
disturbances,  nutritional  disorders,  entire  food  intolerance, 
and  death.  Thus  I  believe  that  this  stool  is  largely,  though 
indirectly,  responsible  for  the  vast  infant  morbidity  and 
mortality  occurring  during  the  first  year  of  life. 


266  DIARRHEA. 

TREATMENT. 

Breast  Babies. —  In  the  cases  just  cited  the  maternal 
milk  should  be  analyzed.  If  this  be  impossible  it  must  be 
assumed  that  the  milk  contains  too  much  fat  or  too  much 
sugar  or  both  for  the  individual.  An  attempt  must  be  made 
to  readjust  these  through  the  mother's  diet  and  through 
exercise  according  to  the  methods  described  on  page  35, 
Chapter  I. 

It  is  primarily  important  to  reassure  the  mother  re- 
peatedly. If  maternal  mental  quietude  can  be  secured  the 
digestion  of  the  infant  will  be  materially  assisted.  The 
baby  must  be  weighed  thrice  weekly  in  the  presence)  of  the 
mother,  who  must  be  made  to  realize  the  desire  of  the 
physician  to  deal  honestly  with  her.  This  instance  is  an 
exception  to  the  rule  against  too  frequent  weighing.  At 
the  same  time  the  mother  must  be  assured  that,  as  long  as 
her  baby  gains,  not  very  much  can  be  wrong.  If  once 
maternal  control  is  secured  the  problem  will  be  easy,  for 
not  infrequently  weeks  and  even  months  are  consumed  be- 
fore the  stools  become  normal  in  these  babies,  and  some- 
times they  never  do  so  until  weaning  is  accomplished.  For 
a  while  the  stools  may  appear  quite  normal,,  when  they 
again  relapse.  The  suggestion  of  Dr.  Frank  Neff,  of  Kan- 
sas City,  Mo.,  that  the  maternal  milk  be  drawn  and  skimmed, 
I  consider  a  good  one,  though  not  always  practical. 

If  vomiting  occurs  the  feeding  interval  must  be  length- 
ened to  two  and  one-half  to  three  hours  and  even  to  four 
hours.  The  infant  must  not  be  kept  at  the  breast  too  long 
—from  five  to  fifteen  minutes  being  sufficient.  Nor  must  it 
receive  its  meal  too  fast.  The  mother  can  control  the  flow 
of  milk  by  making  pressure  upon  the  nipple.  The  infant 
must  not  be  permitted  to  suck  air,  and  after  each  feeding  it 


TREATMENT.  267 

is  held  erect  and  its  abdomen  gently  compressed  in  order  to 
assist  in  the  easy  expulsion  of  gas.  Many  of  these  babies 
are  benefited  by  instituting  a  "hunger  period"  for  twenty- 
four  hours,  during  which  time  only  weak  tea  sweetened 
with  saccharin,  or  barley-water,  is  given,  or  by  giving  them 
just  before  nursing  a  half-ounce  or  so  of  plain  boiled  water 
or,  preferably,  thin  barley-water.  This  dilutes  the  mother's 
milk,  assists  in  dividing  up  the  curd,  and  often  causes  the 
stools  to  become  normal,  at  least  for  the  time  being.  A 
carminative  water,  as  peppermint-water,  anise-seed  water, 
soda-mint  water,  or  dill-water,  may  be  useful  in  either  pre- 
venting or  curing  the  colic.  A  peaceful  night  may  be 
secured  for  the  entire  household  by  giving  the  infant  a  bath, 
the  temperature  of  which  should  be  between  100°  and 
110°  F. 

Medicinal. —  Occasionally  a  dose  of  from  I  to  3  drams 
of  castor  oil  in  connection  with  a  twenty-four  hour  "hunger 
period"  may,  if  associated  with  energetic  dietetic  treatment 
of  the  mother,  cut  short  an  attack.  I  have  an  impression, 
growing  stronger  with  increasing  experience,  that  physi- 
cians too  readily  administer  purgatives,  especially  calomel 
and  castor  oil,  in  cases  of  diarrhea  occurring  in  sucklings. 
It  is  true  that  the  purgative  sweeps  the  intestinal  tract  of 
the  offending  substance,  but  it  is,  in  addition,  itself 
decidedly  irritating  and  may  continue  the  digestive  disturb- 
ance for  some  time  before  it  itself  is  entirely  eliminated 
from  the  gut.  Consequently  it  takes  a  considerable  time 
before  the  relaxed  and  irritated  bowel  regains  its  tone. 
The  danger  from  this  state  of  affairs  is  not  so  menacing  in 
the  breast-fed  as  in  the  bottle-fed,  for  the  irritant  effect  of 
the  purgative  may  be  all  that  is  required  to  induce  a  food 
intolerance,  the  consequences  of  which  may  be  far-reaching 


268  DIARRHEA. 

and  even  fatal.  The  "hunger  period"  would  appear  to*  be 
sufficient,  meanwhile  permitting  the  diarrhea  to  cure  itself, 
i.e.,  allowing  the  irritating  substance  in  the  food,  which 
causes  the  disturbance,  to  act  as  the  purgative,  the  bowel 
thus  ridding  itself  of  the  offending  material  without  the 
assistance  of  other  irritants.  Of  the  two,  calomel  and  cas- 
tor oil,  the  oil  is  to  be  preferred  as  the  least  irritating. 
Should  the  diarrhea  continue  longer  than  appears  necessary 
after  the  withdrawal  of  the  food,  and  should  the  toxic 
symptoms  persist  in  their  intensity  or  be  unusually  severe  at 
the  outset,  then  a  sufficient  dose  of  oil  may  be  administered, 
but  it  must  not  be  repeated.  Thus  it  would  appear  best  to 
advise  that  all  purgatives  should,  in  sucklings  suffering  with 
diarrhea,  be  administered  with  caution  and  only  after 
mature  judgment. 

The  following  may  be  administered  with  excellent  effect 
just  before  or  immediately  after  food.  It  may  be  given 
in  barley-water  or  in  plain  water: — 

B  Extract  pancreatin, 

Taka-diastase    aa  gr.  ij. 

Pul.  aromat., 

Sac.  albae    aa  gr.  iij. 

M.  et  ft.  chart,  no.  j.    Mitte  no.  xij. 
Sig. :  As  above  directed. 

Especially,  if  combined  with  a  hot  bath,  sodium  bromid 
will  often  soothe  the  babe  to  peaceful  slumber : — 

5  Sodii  bromidi    gr.  xxxij. 

Tr.  opii  camph., 

Aquae  menthae  pip.,  or 

Aquae  anisi 3iss. 

Syr.  simplicis q.  s.  ad   fSij. 

M.  ft.  sol. 

Sig. :   As  above  directed  or  f  3j  t.  i.  d.  or  p.  r.  n.  in  aqua. 


TREATMENT.  269 

Bismuth  and  intestinal  antiseptics  play  no  part  in  the 
treatment  of  diarrhea. 

Should  no  improvement  occur  the  infant  must  be  re- 
moved from  the  breast  and  placed  upon  eiweissmilch  or 
upon  buttermilk-and-flour  mixture  sweetened  with  sac- 
charin. Meanwhile  the!  breast  function  is  maintained  by 
the  systematic  use  of  the  breast-pump.  When  the  stools 
again  become  normal  the  infant  is  again  placed  upon 
maternal  milk.  If,  however,  one  or  more  relapses  ensue, 
suitable  artificial  feeding  must  be  instituted. 

Treatment  in  the  Bottle-fed. — This  too  is  largely  die- 
tetic. The  following  routine  has  many  times  yielded  good 
results :  An  initial  purgative  of  castor  oil  may  or  may  not 
be  administered,  in  keeping  with  the  ideas  just  discussed. 
Calomel  I  have  abandoned,  as  its  action  is  too  slowly 
inaugurated;  because  it  is  too  irritating,,  and  also  because 
its  effect  may  be  constipating  and  it  must  therefore  be 
supplemented  by  castor  oil.  A  "hunger  period"  of  from 
twenty-four  to  thirty-six  hours  is  instituted.  The  infant 
receives  nothing  but  weak  tea  sweetened  with  saccharin 
(i  gr.  to  the  quart)  or  barly- water  salted  to  taste  and 
sweetened  in  a  similar  manner.  Finkelstein's  eiweissmilch, 
also  sweetened  with  saccharin  if  necessary,  is  now  ad- 
ministered. However,  in  many  instances  eiweissmilch1  is 
not  available  in  America.  I  then  make  use  of  the  Blockley 
buttermilk  mixture,  omitting  the  sugar  and  sweetening 
with  saccharin  if  the  infant  rejects  it  unsweetened  (Chapter 
III,  page  124).  This  is  practically  eiweissmilch  except  that 
it  does  not  contain  the  curd  of  an  extra  litre  of  milk.  It  is, 
like  eiweissmilch,  poor  in  fat,  poor  in  sugar,  and  rich  in 
protein,  which  is  finely  comminuted.  It  is  sterile.  It  thus 
provides  all  that  eiweissmilch  does  and,  in  addition,  it 


270  DIARRHEA. 

contains  cooked  wheat-flour,  the  starch!  of  which  is  very 
valuable  in  these  cases.  Furthermore  it  is  much  cheaper 
and  very  easily  made.  Instead  of  either  the  eiweissmilch 
or  the  buttermilk,  Larosan  makes  a  very  useful  substitute. 
This  is  highly  recommended  by  Prof.  Dr.  Wilhelm  Stoeltz- 
ner  (Halle),  its  originator.  It  is  a  calcium  casein  in 
powder  form.  It  is  a  light,  dry  powder,  and  is  very  cheap. 
This  preparation  is  indicated  in  all  the  acute  and  chronic 
dyspepsias.  It  is  commonly  employed  by  adding  2/3  ounce 
to  i  pint  of  milk  and  I  pint  of  diluent.  In  weak,  debilitated 
children  1/3  quart  of  milk  and  2/3  quart  of  diluent  may  be 
employed  with  2/3  ounce  of  Larosan.  In  older  children  2/3 
ounce  of  Larosan  may  be  added  to  I  quart  of  whole  milk. 
The  effect  of  this  substance,  according  to  Stoeltzner,  upon 
the  character  of  the  stools,  is  often  shown  within  twenty- 
four  hours.  Personal  experience  with  this  substance  has 
been  satisfactory  in  a  dozen  or  so  cases. 

Shortly  after  the  use  of  any  one  of  these  preparations, 
if  the  case  be  not  too  severe  and  if  it  progresses  favorably, 
the  stools  will  become  thick  and  present  a  characteristic 
dry,  crumbly,  brownish-yellow  appearance.  This  is  the 
typical  eiweiss  stool.  It  consists  largely  of  calcium  soap. 
Its  incidence  is  always  a  valuable  and  favorable  sign. 
These  preparations  are  continued  for!  some  days.  Grad- 
ually carbohydrate  is  added  in  the  form  of  either  cane-sugar 
or  one  of  the  preparations  of  maltose,  as  Mead-Johnson's 
Dextri-Maltose,  Loeflund's  Food  Maltose,  or  Soxhlet's 
Nahrzucker.  The  stools  are  constantly  scrutinized  and,  if 
they  continue  normal,  the  percentage  of  additional  carbo- 
hydrate is  by  gradual  steps  increased  to  5,.  toi  6,  or  to  7 
per  cent.  This  is  necessary  to  maintain  bodily  heat  and  to 
provide  for  a  reasonable  gain  in  weight. 


TREATMENT.  271 

As  soon  as  a  gain  is  inaugurated,  other  conditions  being 
normal,  after  omitting  one  or  two  feedings,  an  immediate 
return  is  made  to  some  whole-milk  formula,  the  character 
of  which  depends  upon  the  age  and  weight  of  the  child.  It 
is  best  to  start  with  weak  dilutions  of  skimmed  milk,  and 
then  to  proceed  to  weak  dilutions  of  whole  milk  (say  i 
part  of  milk  and  3  parts  of  water)  and  to  gradually  increase 
the  strength  of  the  milk.  Cane-sugar  or  some  maltose 
preparation  is  still  employed  to  provide  carbohydrate,  and 
the  diluent  of  the  milk  should  be  some  starchy  preparation, 
preferably  barley-water,  wheat-flour  water  or,  still  better, 
arrowroot-water.  This  provides  an  excellent  means  of 
attenuating  the  curd  of  cows'  milk,  rendering  it  digestible. 
The  digestibility  of  the  milk  may  be  decidedly  increased  by 
pancreatization  or  by  using  flour  ball  and  pancreatin,  or 
Benger's  Food.  If  there  be  a  tendency  toward  looseness  of 
the  bowels  the  sugar  should  be  markedly  reduced  or  tem- 
porarily omitted.  Meanwhile  5  to  10  grains  of  fullers' 
earth  is  administered  internally  in  order  to  thicken  the 
stools. 

Should  there  at  any  time  occur  a  real  relapse,  the  treat- 
ment just  outlined  must  be  repeated.  The  danger,  however, 
is  that  after  two  or  more  attacks  the  strength  of  the  pa- 
tient is  so  low  that  it  is  impossible  for  the  infant  to  support 
another  "hunger  period,"  as  the  tolerance  for  food  of  any 
kind  may  be  so  depressed  as  to  prevent  the  infant  from 
receiving  sufficient  nourishment  to  sustain  life,  and  dissolu- 
tion ensues.  In  other  words,  the  food  tolerance  is  far  be- 
low the  food  minimum  (von  Pirquet). 

Where  marked  intolerance  for  sugar  does  not  exist, 
weak  dilutions  of  Ramogen,  somatose  milk,  and  of  con- 
densed milk  form  valuable  adjuncts  in  the  treatment  of 


272  DIARRHEA. 

diarrhea.  They  are  of  especial  use  as  go-betweens,  as  it 
were,  during  the  period  of  starvation  and  the  time  when  a 
return  is  again  made  to  skimmed  milk  or  to  whole-milk 
dilutions.  Even  in  cases  where  sugar  can  be  determined  as 
the  primary  cause  of  the  intestinal  upset,  these  substances 
may  be  of  use  as  tolerance  for  carbohydrate  is  again  grad- 
ually established. 

Treatment  Other  Than  by  Diet.— If  the  infant  has  lost 
much  water  this  must  be  supplied  by  the  drop^method  per 
rectum,  by  mouth  in  definite  amounts,  by  the  drop-method 
by  mouth,  or  by  hypodermoclysis,  according  to  the  urgency 
of  the  indication  (Chapter  XIII).  Plain  tap- water  may  be 
employed,  but  normal  saline  solution  is  perhaps  preferable. 
A  solution  containing  I  dram  of  sodium  chlorid  and  i  dram 
of  sodium  bicarbonate  to  the  pint  is  the  one  which  I  com- 
monly employ. 

If  the  temperature  be  high,  especially  during  the  sum- 
mer months,  frequent  bathing  is  essential.  It  combats  shock 
and  soothes  the  infant's  nervous  system.  The  bath  should 
be  warm  (100°  F.)  and  gradually  cooled  (80°  to  75°  F.). 
The  cold  bath  is  abominable.  An  excellent  method  is  that 
proposed  by  Henry  Illoway,  M.D.,  of  New  York,  who 
employs  the  wet  pack,  consisting  of  a  sheet  wrung  out  of 
tap-water.  The  infant  is  enveloped  in  this  and  permitted 
to  lie  in  it  for  hours.  When  it  gets  warm  or  when  the 
infant's  temperature  starts  to  rise,  the  wet  sheet  is  renewed 
and  an  ice-cap  is  kept  to  the  head.  The  wet  pack  not  only 
reduces  temperature,  but  has  an  excellent  effect  upon  the 
nervous  symptoms,  causing  the  infant  in  most  cases  to  drop 
off  into  a  refreshing  slumber.  The  etiologic  influence  of 
external  heat  is  decidedly  mitigated  and  the  pack  often 
seems  to  assist  in  the  actual  reduction  of  the  number  of 
stools. 


TREATMENT.  273 

Colonic  irrigation  as  a  routine  method  of  treatment  is, 
in  my  judgment,  of  very  little  use  and  frequently  does  harm 
by  increasing  the  amount  of  mucus,  if  it  be  too  long  con- 
tinued. As  an  initiatory  remedy  employed  but  once,  it  may 
render  signal  service  in  reducing  temperature,  lessening 
toxemia,  and  by  ridding  the  bowel  of  a  mass  of  offensive 
material.  Likewise  in  cases  of  actually  demonstrative  sig- 
moidal  and  rectal  ulceration  occurring  as  the  result  of 
secondary  infection,  and  in  which  blood  is  found  in  the 
stools,  daily  or  bidaily  flushing  of  the  bowel  with  a  warm 
2  per  cent,  solution  of  tannic  acid  is  of  much'  value.  About 
2  quarts  should  be  employed. 

Vomiting  in  the  beginning  of  severe  cases  of  intoxica- 
tion is  a  benign  process  with  which  no  attempt  should  be 
made  to  interfere.  Stomach  washing  is  valuable  late  in 
the  course  of  severe  cases  where  the  vomiting  occurs  as  the 
result  of  toxemia.  One  or  two  washings  may  be  sufficient. 
A  solution  containing  i  dram  of  bicarbonate  of  soda  to  the 
pint  of  water  is  best.  It  should  be  used  warm.  A  point  in 
technique  may  be  of  considerable  service.  After  the  fluid 
returns  clear,  the  tube  is  not  withdrawn,  but  a  feeding  is 
poured  into  the  funnel  and  allowed  to  enter  the  stomach. 
The  tube  is  pinched  and  withdrawn  by  a  swift  movement 
between  gags.  A  meal  given  in  this  manner  is  often  re- 
tained when  otherwise  it  would  be  vomited  (Chapter  VII). 

Medicinal. — My  feeling  is  that  drugs  should  play  a  very 
small  part  in  the  management  of  these  cases.  To  secure 
rest  of  the  nervous  system  and  to  conserve  for  the  infant  its 
energy,  a  hypodermic  injection  of  from  1/80  to  1/i0o  grain 
of  morphin  sulphate  is  decidedly  useful.  Recognizing 
that  the  physician  is  often  forced  to  administer  medicine 
against  his  better  judgment,  those  remedies  only  should  be 

18 


274  DIARRHEA. 

employed  which  do  the  least  harm.  Calomel  and  intestinal 
antiseptics  are  practically  useless  and,  for  reasons  already 
enunciated,  should  not  be  employed.  Digestants  like  pan- 
creatin  and  taka-diastase  or  a  drop  of  the  tincture  of  nux 
vomica  are  at  times  good  and  helpful.  Bismuth  I  believe 
to  be  inert  as  to  its  effects  upon  this  condition,  with  the 
possible  exception  of  the  subgallate  which  I  have  employed 
in  large  doses  (gr.  xx  every  three  hours)  in  combination 
with  10  minims  each  of  the  tincture  of  kino,  camphorated 
tincture  of  opium,  and  listerine,  with  cinnamon-water  as  the 
vehicle.  The  mixture  was  discontinued  as  soon  as  hem- 
orrhage was  controlled.  Czerny  employs  the  juice  of 
dried  or  fresh  blue  berries.  In  older  children  he  administers 
this  with  potatoes  in  the  form  of  a  soup.  I  have  in  two  or 
three  cases  of  severe  bleeding  employed,  along  with  tannic 
acid  irrigations,  %  grain  of  emetin  hydrochlorid,  I  think, 
with  good  effect. 

DIARRHEA  IN  CHILDREN  WITH  TEETH. 

The  problem  is  not  so-  difficult.  The  presence  of  teeth 
indicates  that  the  intestinal  tract  is  ready  to  care  for  food 
which  requires  previous  comminution.  Therefore  the 
source  of  the  diarrhea,  viz.,  milk,  may  be  omitted  from  the 
diet  at  once.  An  initial  dose  of  castor  oil  usually  in  these 
children  does  good  and  rarely  any,  or  but  little,  harm.  Not 
less  than  y2  ounce  should  be  administered.  Recourse  should 
be  had  to  starches,  preferably  well-cooked  rice  (three 
hours),  arowroot- jelly,  wheat-flour  gruel,  farina,  cream  of 
wheat,  mashed  baked  potato,  stale  bread,  mutton-broth  and 
soft-boiled  egg.  While  on  this  diet,  which  may  be  con- 
tinued for  weeks,  improvement  speedily  occurs.  The  diges- 
tion may  be  materially  assisted  by  the  use  of  pancreatin  and 


DIARRHEA    IN    CHILDREN    WITH    TEETH.  275 

of  taka-diastase.  Two  grains  of  each  are  administered 
every  four  hours.  Recovery  will  in  most  instances  ensue 
without  the  use  of  medicaments.  Should  these  be  found 
necessary  some  preparation  containing  tannic  acid,  as  kino, 
geranium,  catechu,  or  tannigen,  will  be  found  to  be  the  most 
serviceable  if  used  in  combination  with  small  doses  of  pare- 
goric. Fullers'  earth  (gr.  x  every  four  hours)  will  also 
thicken  the  stools.  As  soon  as  the  latter  become  normal  a 
return  should  be  made  to  milk  preparations — as  eiweiss- 
milch,  buttermilk-and-flour  mixture  without  sugar,  but 
sweetened  with  saccharin,  or  skimmed  milk,  1/3  diluted  2/3 
with  arrowroot-water,  with  the  addition  of  2/3  ounce  of 
Larosan  and  the  whole  sweetened  with  saccharin.  Gradu- 
ally dilution  of  whole  milk  is  made  and  the  Larosan  is 
omitted.  Sugar  is  slowly  added  for  a  while.  Flour  ball 
and  pancreatin  may  be  employed,  or  Benger's  Food.  Any- 
way, plain  whole  milk  should  be  cautiously  reached  and  this 
should  be  boiled  for  some  time  after  the  attack.  In  using 
skimmed  milk  under  all  circumstances  this  should  be  em- 
ployed by  skimming  the  best  milk  obtainable,  at  home. 


CHAPTER  X. 
SPASMOPHILIA. 

Synonyms. —  Spasmophilic  diathesis,  Tetany. 

Definition  and  Nature. — Under  the  term  spasmophilia 
are  correlated  the  evidences  of  nervous  irritability  in  infants 
and  young  children  which  have  been  known  to  the  pro- 
fession for  a  long  time.  These)  conditions  are  mainly 
laryngospasm,  carpopedat  spasm,  tetany,  and  convulsions. 
Instead  of  regarding  each  as  a  separate  and  distinct  disease 
with  a  special  etiology  and  special  therapeutics,  under  the 
term  spasmophilia,  they  have  been  united  as  a  single  entity 
depending  upon  a. basic  cause  or  diathesis  which  is  deter- 
mined by  certain  metabolic  disturbances  which,  though  not 
definitely  proven,  certainly  exist,  and  which  depend  upon 
dietetic  errors.  Spasmophilia  may,  therefore,  be  character- 
ized as  a  state  of  abnormal  nervous  irritability.  Most  cases 
occur  after  the  third  month,  although  there  are  exceptions 
to  this,  some  earlier  instances  being  met  especially  in  pre- 
mature infants.  Rarely,  if  ever,  are  cases  seen  in  the  breast- 
fed,— a  fact  to  which  much  significance  must  be  attached. 
In  the  Waisenhaus  und  Kinderasyl  in  Berlin  over  50  per 
cent,  of  the  infants  which  are  artificially  fed  show  the  evi- 
dences of  this  diathesis.  The  vast  majority  of  these  babies 
receive  eiweissmilch. 

PATHOLOGIC  ETIOLOGY. 

Before  1890  the  Spasmophilic  diathesis  was  little  under- 
stood. Escherich  and  Lows  first  noted  the  constant  asso- 

(276) 


PATHOLOGIC   ETIOLOGY.        .  277 

ciation   of   convulsions   and   laryngospasm    with    increased 
nerve  irritability. 

About  the  same  time  Gai  and  Ganghofner  noted  the 
association  of  eclampsia  (convulsions)  and  irritability  of 
the  nerves,  and  concluded  that  the  former  occurred  as  a 
consequence  of  the  latter.  Thiemich  and  Mann  were  the 
first  to  study  and  to  measure  the  electrical  reactions  of  these 
cases,  and  to  determine  the  normal  number  of  milliamperes 
which  were  sufficient  to  cause  muscular  contraction.  It 
was  discovered  that  the  minimum  amount  of  galvanic  cur- 
rent necessary  to  produce  a  contraction  of  a  muscle  in  a 
normal  infant,  when  the  anode  was  opened,  registered  5 
milliamperes. 

NUMBER  OF  -AMPERES  XECESSARY  TO  PRODUCE  MUSCULAR  CONTRACTION 
IN  A  NORMAL  CHILD. 

C.  C.  C.  i   A.  C.  C.  2  A.  O.  C.  3   C.  O.  C.4 

Under  8  weeks    2.61  2.92  5.12  9.28 

About  8  weeks    1.41  2.44  3.63  8.22 

NUMBER  OF  AMPERES  NECESSARY  TO  PRODUCE  MUSCULAR  CONTRACTION 
IN  MANIFEST,  LATENT  AND  PASSED  SPASMOPHILIA. 

C.  C.  C.  A.  C.  C.  A.  O.  C.  C.  O.C. 

Manifest    0.63  i.n            0.55  1.94 

Latent    0.70  1.15            0.95  2.23 

Passed 1.83  1.72            2.34  7.904 

These  figures  are  averages,  but  serve  to  indicate  that  in 
the  presence  of  spasmophilia  decidedly  less  current  is  re- 
quired to  produce  the  muscular  contractions. 

Finkelstein  first  named  this  state  of  nervous  excitability 
spasmophilia.  Inase,  working  with  Escherich,  noted  the 


1  Cathode-closing  contraction. 

2  Anode-closing  contraction. 

3  Anode-opening  contraction. 

4  Cathode-opening  contraction. 


278  SPASMOPHILIA. 

presence  of  hemorrhages  into  the  parathyroids  in  many  new- 
born babies,  and  to  the  destruction  of  the  parenchyma  of 
these  glands,  occurring  as  the  result  of  these  hemorrhages, 
Escherich  ascribed  the  cause  of  spasmophilia.  Finkelstein 
objected  on  the  ground  that,  if  the  causative  hemorrhage 
occurred  at  birth,  it  was  difficult  to  understand  why,  with 
but  rare  exceptions,  the  symptoms  did  not  appear  until  three 
months  later.  He  proposed  that  the  cause  was  due  to  faulty 
metabolism  by  reason  of  which  some  substance,  which  he 
did  not  name,  entered  the  blood.  He  inclined  to  the  view, 
however,  that  the  salts  of  the  whey  of  cows'  milk  were  the 
responsible  factors,  because  it  is  well  known  that  nearly  all 
cases  occur  in  the  artificially  reared,  and  he  claimed  further 
that  the  symptoms  could  actually  be  produced  by  whey 
feeding.  This  statement,  however,  requires  confirmation. 

Stoeltzner  (Halle),  after  feeding  lime  to  children,  de- 
cided that  this  caused  the  increased  nervous  response  to  the 
electric  current,  and  concluded  that  with  artificial  feeding 
there  is  an  increased  accumulation  of  lime  in  the  system, 
especially  since  there  is  at  least  five  times  as  much  lime  in 
cows'  milk  as  in  human  milk.  This  he  claimed  increased 
the  nerve  irritability.  On  the  other  hand,  Quest  found  that 
in  the  brains  of  children,  dead  of  tetany,  there  was  a  defi- 
ciency of  lime-salts.  His  conclusions,  therefore,  exactly 
reversed  those  of  Stoeltzner,  and  he  found  that  dogs,  fed 
upon  a  diet  poor  in  lime,  exhibited  diminished  resistance 
to  the  electric  current.  In  confirmation  of  this,  and  also 
linking  together  the  theory  of  a  disturbance  of  metabolism 
on  account  of  impaired  parathyroid  function  with  that  of 
lime  starvation,  MacCallom  found  a  deficiency  of  lime  in 
dogs  in  whom  the  parathyroids  had  been  extirpated. 

Up  to  the  present  time,  therefore,  it  must  be  stated  that 


PREDISPOSING   CAUSES.  279 

the  exact  etiologic  factor  or  factors  have  not  been  deter- 
mined, although  it  would  appear  that  the  truth  lies  some- 
where between  the  theory  of  lime  starvation  and  that  of  dis- 
turbed function  of  the  parathyroids.  The  former  occurs 
either  as  a  consequence  or  as  an  association  of  the  latter. 
Much  credence  must  be  given  to  the  lime-starvation  theory, 
because,  recently,  the  best  results  have  been  obtained  after 
treatment  with  calcium  bromide. 

PREDISPOSING  CAUSES. 

The  fact  that  the  same  exciting  factor  does  not  induce 
spasmophilia  in  every  child  permits  us  to  assume  that 
heredity,  as  far  at  least  as  predisposition  is  concerned,  plays 
a  role  of  no  mean  importance.  The  disease  is  not  infre- 
quently seen  in  many  children  of  the  same  parents.  This  in 
itself,  however,  offers  no  convincing  proof  that  the  same 
exciting  etiologic  influence  may  be  responsible  in  each  case. 
It  has,  nevertheless,  been  noted  that  parents  who  present 
neuropathies  are  likely  to  have  spasmophilic  children. 

The  disease  is  commonly  confined  to  those  infants  who 
are  artificially  reared.  Especially  is  this  true  where  the 
feeding  has  been  mismanaged,  and  where  the  food,  in  both 
quality  and  quantity,  has  been  incorrect.  As  a  consequence 
of  this,  the  occurrence  of  frequent  digestive  disturbances 
has  interfered  with  the  proper  progression  of  the  infant's 
nutrition  and  development.  Babies  who  are  underfed,  as 
well  as  those  who  are  overfed,  however,  are  pre-eminently 
predisposed  to  this  condition,  especially  if  the  malnutrition  is 
associated  with  chronic  digestive  disturbances. 

All  exliausting  diseases,  prolonged  infections  especially, 
predispose  to  spasmophilia.  It  is  also  worthy  of  note  that 
the  acute  infectious  diseases,  notably  pneumonia,  occur 


280  SPASMOPHILIA. 

with  greater  severity  in  spasmophilics.  These  cases  present 
the  highest  temperature,  the  greatest  degrees  of  toxemia, 
and  consequently  the  highest  mortality.  Further,  by  means 
of  spasmophilia,  we  have  an  explanation  as  to  why  so  many 
of  the  acute  infections,  again  notably  pneumonia,  are  in- 
augurated in  many  infants  by  convulsions  instead  of  by  the 
rigor  of  the  adult.  The  toxin  is  sufficient  to.  transform  a 
latent  spasmophilia  into  a  manifest  one. 

Acute  digestive  disturbances,  as  well  as  chronic,  may 
also  induce  manifest  tetany,  a  term  which  will  be  presently 
described.  Thus  is  explained  the  occurrence  of  convulsions 
in  an  infant  following  the  ingestion  of  some  indigestible 
substance.  We  formerly  regarded  this  as  a  reflex  or  toxic 
phenomenon,  but  had  no  means  of  explaining  the  method 
of  its  production,  or  why  one  child  escaped  and  the  other 
did  not.  The  reason  is  that  the  infant  is  spasmophilic,  i.e., 
the  electrical  excitability  of  its  nervous  system  is  intensified, 
and  the  mechanical  or  toxic  irritation,  or  both,  are  sufficient 
to  cause  this  latent  status  to  become  manifest. 

Season  exerts  some  influence.  Most  cases  are  seen  be- 
tween January  and  April.  Many  occur  in  the  autumn,  and 
least  are  met  during  summer. 

Sex  does  not  appear  to  have  any  effect. 

The  association  of  rickets  and  spasmophilia  in  the  same 
individual  can  be  frequently  noted.  What  interdependence 
exists  between  these  two  conditions  has  not  been  clearly 
established,  although  their  frequent  coexistence  must  be 
more  than  coincidental.  It  is  probably  true  that  each  de- 
pends upon  the  same  disturbance  of  metabolism  that  is  pro- 
duced by  improper  feeding.  Both  are  undoubtedly  benefited 
by  codliver  oil  and  phosphorus. 


SYMPTOMS.  281 

SYMPTOMS. 

These  may  be  classified  under  two  groups: — 

A.  Symptoms  of  latent  spasmophilia,  or  tetany. 

B.  Symptoms  of  manifest  spasmophilia,  or  tetany. 
Both  of  these  conditions  must  be  carefully  studied  in 

order  to  exercise  control  over  the  diathesis,  for  at  any  time 
a  latent  spasmophilia  may  be  transformed  into  the  manifest 
type  with  fatal  results.  Each  has,  however,  a  distinct 
symptomatology,  and  each  a  distinct  therapeusis.  The 
treatment  of  manifest  tetany  must  be  prompt,  while  that  of 
the  latent,  while  just  as  important,  need  not  be  so  hasty. 

A.  Latent  Spasmophilia,  or  Tetany. — This  is  character- 
ized by 

1.  Certain  reflex  phenomena. 

2.  Abnormal  electrical  reactions. 

i.  Reflex  Phenomena. — These  are  very  important  in 
establishing  the  presence  of  the  diathesis.  They  must  be 
divided  into  nervous  reflex  phenomena  and  muscular  reflex 
phenomena.  Under  the  nervous  reflex  phenomena  we  have 
(a)  facial  phenomenon,  or  Chvostek's  sign;  (&)  Trous- 
seau's sign.  Under  the  muscular  phenomena  are  included 
(a)  the  peroneus  reflex  and  (b)  the  lip  sign  of  Thiemich. 

B.  Manifest  Spasmophilia,  or  Tetany. — This  includes 

1.  Laryngospasmus. 

2.  Carpopedal  spasm. 

3.  Eclampsia. 

4.  Hard  edema  of  hands  and  feet. 

There  are  other  symptoms  of  more  or  less  importance 
which  will  be  described  in  their  order.  Before  detailing 
the  features  of  both  latent  and  of  manifest  tetany,  the  fol- 
lowing is  therefore  presented  as  a  summary  of  the  impor- 


282 


SPASMOPHILIA. 


tant  features,  in  order  that  they  may  be  crystallized  in  the 
student's  mind: — 

i.  Facial 

phenomenon, 

or 
f   i.  Nervous  -;          Chvostek's 


f   i.  Reflex 
phenomena  * 


f  A.  Latent 


Spasmo- 
philia, 

or 
Tetany 


sign. 

2.  Trousseau's 
sign. 


f    i.  Peroneus 
reflex. 

2.  Muscular  <|    2-  Lip  phe- 

nomonon  of 
Thiemich. 


2.  Abnormal  electrical  reactions. 


1.  Laryngospasmus. 

2.  Carpopedal  spasm. 
I  B"  Manifest       3    Eclampsia. 

[   4.  Hard  edema  of  hands  and  feet. 


Facial  Phenomenon,  or  Chvostek's  Sign. — Search  should 
be  made  for  this  in  every  child  after  2  months,  as  it  is  a 
constant  feature  of  both  manifest  and  of  latent  tetany.  It 
may  be  positive  on  one  side  of  the  face  only.  Hence  both 
sides  should  always  be  tested.  It  is  elicited  by  tapping 
lightly  with  a  percussion  hammer  (plexor — Fig.  46)  on 
the  face  just  below  the  zygomatic  process  of  the  superior 
maxilla.  This  is  followed  by  a  contraction  (sometimes 
very  slight  and  evanescent,  and  therefore  the  most  careful 
scrutiny  must  be  exercised)  of  the  muscles  of  the  face 
and  of  the  upper  eyelids,  and  of  the  wing  of  the  nose. 
The  facial  contraction  may  not  occur,  and  the  phenomenon 
may  be  confined  to  the  upper  eyelid  alone.  Therefore,  this 
portion  of  the  face  should  be  most  carefully  visualized. 


SYMPTOMS.  283 

The  contraction  in  any  event  is  faint  or  intense,  depending 
upon  the  degree  of  nervous  excitability.  The  features  must 
be  in  repose  when  this  test  is  made,  and,  therefore,  it  can- 
not be  successful  if  the  baby  is  crying.  While  this  sign  is 
present  in  practically  every  case  of  spasmophilia,  it  is  not 
pathognomonic  of  this  affection.  At  least  the  author  has 
been  able  to  demonstrate  it  in  cases  of  tuberculous  menin- 
gitis. It  may  be  that  these  infants  were  spasmophilics  as 
well.  However,  positive  reliance  should  not  be  placed  upon 
this  sign  alone,  and  every  case  in  which  the  condition  is 
suspected  should  be  studied  for  the  electrical  reactions  as 
well  if  this  be  at  all  possible. 


Fig.  46. — Percussion  hammer. 


Trousseau's  phenomenon  occurs  as  the  result  of  pres- 
sure exerted  upon  the  main  nerve  and  blood-vessel  of  a  long 
extremity,  usually  the  arm.  The  pressure  is  applied  either 
by  the  thumb  and  forefinger  of  the  examiner  encircling  the 
upper  arm,  or  by  tying  a  band,  rubber  or  otherwise,  about 
the  part  sufficiently  firm  to  cut  off  the  circulation  at  the 
wrist.  The  reaction,  if  positive,  may  not  be  seen  at  once. 
Shortly,  however,  the  muscles  of  the  hand  (if  the  band  has 
been  placed  about  the  arm)  or  foot  (if  the  band  has  been 
placed  about  the  thigh)  and  of  the  lower  arm  or  leg  com- 
mence to  contract  and  to  cause  the  extremity  to  assume  the 
characteristic  attitude  of  carpopedal  spasm.  If  this  test  is 
positive  it  indicates  spasmophilia  without  question.  Unfor- 
tunately it  is  not  always  present  and  is,  therefore,  not  so 


284  SPASMOPHILIA. 

reliable  as  Chvostek's  sign.  Further,  it  causes  pain,  and 
parents  often  object  to  its  use,  as  it  appears  cruel  and  un- 
necessarily harsh  to  them.  In  no  case  should  it  be  employed 
until  the  close  of  the  examination. 

The  peroneus  phenomenon  is  obtained  by  tapping  the 
peronei  muscles  on  the  outer  aspect  of  the  leg  with  the  per- 
cussion hammer.  If  positive,  this  causes  the  outer  aspect 
of  the  foot  to  be  drawn  up  and  the  toes  to  be,  raised  and  at 
the  same  time  to  be  slightly  separated.  While  this  reflex 
is  more  reliable  than  Trousseau's,  it  is  not  always  present, 
either.  On  the  other  hand,  stress  must  again  be  laid  upon 
the  fact  that  there  is  never  a  case  of  either  latent  or  of 
manifest  tetany  in  which  Chvostek's  phenomenon  is  absent. 

Lip  Phenomenon. — This  was  first  described  by  Thre- 
mich,  and  is  obtained  by  tapping  the  orbicularis  oris.  This 
causes  the  muscle  to  contract  with  the  result  that  the  lips 
are  closed  and  slightly  protruded  and  appear  as  in  the  act  of 
kissing. 

Abnormal  Electrical  Reactions. — Muscular  contractions 
normally  occur  when  the  galvanic  current  is  applied  to  the 
muscles  of  the  infant.  These  contractions  are  designated 
as  follows: — 

Cathode-closing  contraction  (C.  C.  C.},  i.e.,  when  the 
cathode  is  applied  over  the  muscle  and  the  anode  is  placed 
on  the  abdomen  or  upon  the  back,  a  muscular  contraction 
occurs  when  the  current  is  sufficiently  strong  for  the  in- 
dividual muscle,  at  that  time,  when  the  circuit  is  closed. 

Cathode-opening  contraction  (C.  O.  C.),  the  same  con- 
ditions obtained  as  just  described,  and  the  muscle  contracts 
when  the  circuit  is  opened. 

Anode-closing  contraction  (A.  C.  C.),  the  electrodes  are 
reversed,  i.e.,  the  anode  is  placed  upon  the  muscle  and  the 


SYMPTOMS.  285 

cathode  upon  the  back  or  abdomen.  A  contraction  occurs 
when  the  circuit  is  closed. 

Anode-opening  contraction  (A.  O.  C.),  the  same  con- 
ditions obtain  as  in  the  preceding  except  that  the  circuit  is 
opened. 

It  is  seen  therefore  that  when  making  an  anode  exami- 
nation the  anode  is  placed  upon  the  muscle  and  the  cathode 
upon  the  abdomen  or  back,  and  when  making  a  cathode 
examination  the  cathode  is  placed  upon  the  muscle  ex- 
amined and  the  anode  upon  the  back  or  abdomen.  In 
either  instance  the  electrode  which  is  placed  upon  the 
muscle  is  called  the  "different"  electrode  and  that  placed 
upon  the  abdomen  or  back  is  called  the  "indifferent"  elec- 
trode. The  former  must  always  be  three  square  centi- 
meters in  area,  and  is  usually  placed  upon  the  median  nerve 
just  above  the  bend  of  the  elbow  on  the  anterior  surface  of 
the  arm.  This  nerve  supplies  the  thumb,  the  index-finger, 
the  middle-finger,  and  half  of  the  ring-finger,  and  as  the 
current  is  applied  the  muscular  contractions  in  these  digits 
are  noted,  especially  that  of  the  index-finger.  The  latter 
must  be  not  less  than  fifty  square  centimeters.  The  so- 
called  normal  electrical  reaction,  indicating  the  amount  of 
galvanic  current  necessary  to  produce  a  muscular  contrac- 
tion in  a  normal  infant,  is  tabulated  on  page  277.  Refer- 
ence to  the  same  table  will  demonstrate  that,  under  abnor- 
mal conditions,  less  current  is  required  to  bring  about  a 
contraction.  These  are  the  so-called  abnormal  electrical 
reactions.  They  are  patho  gnomonic  of  latent  tetany,  and 
occur,  of  course,  as  well  in  manifest  tetany. 

The  following  will  serve  as  a  practical  example!  of  what 
occurs  in  a  case  of  spasmophilia.  The  electrodes  are  so 
placed,  and  the  switch  on  the  electrical  apparatus  so  ad- 


286  SPASMOPHILIA. 

justed,  that  the  cathode  becomes  the  "different"  electrode. 
The  absolute  size  of  the  milliamperage  required  to  produce 
a  cathodal-opening  contraction  is  the  indicator  of  the  sever- 
ity of  the  spasmophilia.  Look  for  the  smallest  amount  of 
milliamperage  which  will  produce  a  C.  O.  C.  Suppose  i 
milliampere  of  current  is  flowing  through  the  electrode  as 
shown  on  the  milliamperemeter  and  no  contraction  occurs. 
Slowly  increase  the  current.  Suppose  at  3  milliampere- 
meters  a  C.  C.  C.  takes  place.  With  this  amount  of  current 
the  C.  O.  C.  is  still  negative.  Increase  the  current  to  4 
milliamperemeters.  A  distinct  C.  O.  C.  is  seen.  Decrease 
the  current  very  slowly  so  that  the  smallest  amount  of  cur- 
rent which  will  produce  a  C.  O.  C.  can  be  estimated.  Let 
us  assume  this  to  be  3.5  milliamperemeters,  and  it  may  be 
further  assumed  that  at  3.3  milliamperemeters  no  C.  O.  C. 
occurs,  but  only  the  C.  C.  C.  is  present.  Result:  3.5  milli- 
amperemeters constitute  the  smallest  amount  of  current  that 
will  produce  a  C.  O.  C.  In  normal  children  the  necessary 
amount  of  current  to  produce  a  C.  O.  C.  is  5  rnilliampere- 
meters,  and  anything  less  than  this  indicates  spasmophilia. 

By  means  of  these  electrical  reactions  we  can  best  deter- 
mine the  presence  of  both  latent  and  of  manifest  tetany. 
They  are  present  in  every  case,  although,  when  other  symp- 
toms are  in  evidence,  it  is  unnecessary  to  search  for  them 
in  order  to  reach  a  correct  clinical  diagnosis.  However, 
the  prognosis  and  the  effect  of  treatment  can  be  accurately 
gauged  in  this  manner  and,  therefore,  whenever  possible  the 
reactions  should  be  taken  at  frequent  intervals — daily  at 
first,  then  triweekly,  biweekly,  and  so  on.  Cards  may  be 
kept  on  file,  graphically  illustrating  the  diagnosis  and  prog- 
nosis of  an  individual  case.  If  accurate  electrical  studies 
are  impossible,  the  prognosis  and  the  effect  of  treatment 


SYMPTOMS.  287 

may  be  studied  as  well,  although  less  minutely,  by  fre- 
quently testing  for  the  Chvostek  sign  and  noting  its  gradual 
disappearance. 

Laryngospasmus. — This  is  a  convulsive  state  of  the 
glottis  in  which  a  crowing  sound  occurs  during  inspiration. 
An  attack  is  frequently  inaugurated  during  crying  or  from 
fright.  It  is  commonly  seen  in  older  children  following 
pique,  temper,  or  punishment,  and  who  have  the  underlying 
diathesis.  On  the  other  hand,  an  infant  may  be  awakened 
from  sleep  by  an  attack.  The  crowing  sound  is  characteris- 
tic. It  must  be  distinguished  from  a  similar  sound  which 
occurs  in  infants  but  a  few  weeks  of  age.  This  is  known 
as  stridor  inspiratorius  congenita,  and  is  differentiated  by 
the  age  of  the  infant,  the  absence  of  other  symptoms  and 
of  the  electrical  reactions,  and  by  the  effect  of  antispasmo- 
philic  treatment  upon  true  laryngospasmus.  In  the  latter, 
following  the  spasm  of  the  glottis,  there  is  a  state  of  apnea 
which  is  associated  with  tonic  spasm  of  all  the  respiratory 
muscles,  those  of  the  diaphragm  and  of  the  bronchi  as  well. 
The  child  becomes  pale  and  finally  blue.  As  soon  as  the 
spasm  relaxes,  the  crowing  sound  occurs  as  the  air  enters 
the  lungs.  The  attack  seldom  lasts  longer  than  thirty  or 
sixty  seconds.  The  occurrence  of  the  crow  indicates  the 
end  of  an  attack.  One  attack  may  immediately  follow 
another,  and  the  number  which  may  occur  in  twenty-four 
hours  is  indefinite,  as  many  as  fifty  per  diem  having  been 
noted.  Coma  and  convulsions  may  be  associated  phe- 
nomena, ending  in  death.  If  the  crow  does  not  appear  the 
outcome  is  commonly  fatal.  Escherich  ascribes  the  death 
to  cardiac  failure,  although  this  point  has  not  been  accu- 
rately established,  as  the  respiratory  center  may  as  well  be 
involved  in  the  paralysis.  Mothers  frequently  bring  their 


288  SPASMOPHILIA. 

babies  for  treatment  because,  as  they  say,  "the  baby  holds 
its  breath  when  it  cries."  As  a  matter  of  fact,  no  air  has 
entered  the  lungs. 

Carpopedal  Spasm. — Tonic  contractions  of  the  muscles 
of  the  upper  and  of  the  lower  extremities  characterize  this 
symptom.  The  contractions  last  for  days  and  weeks, 
although  temporarily  they  may  partially  or  completely 
relax.  They  are  so  intense  that  any  attempt  to  straighten 
the  extremities  causes  crying  on  account  of  the  pain  thereby 
induced.  The  forearms  are  flexed  upon  the  arms  and  the 
latter  are  adducted  and  lie  close  to  the  chest-wall.  The 
hands  are  sharply  flexed  upon  the  forearms  and  the  fingers 
are  flexed  as  far  as  the  metacarpophalangeal  articulation, 
from  which  point  the  phalanges  are  extended.  The  thumb 
is  adducted  and  its  tip  frequently  touches  the  tip  of  the  little 
finger. 

Under  the  older  classification  this  condition  of  tonic 
spasm  of  the  upper  and  of  the  lower  extremities  was 
described  as  tetany,  a  distinct  disease,  and  not  as  a  manifest 
symptom  of  the  spasmophilic  diathesis,  and  the  appearance 
of  the  hand  was  described  as  that  of  a  driver  reining  in  his 
horse.  On  the  other  hand,  the  Germans  describe  the  appear- 
ance as  "Geburtshelfer's  hand,"  or  the  attitude  assumed. by 
an  obstetrician  in  delivering  a  child.  The  hand  itself  is 
likened  to  a  little  paw  of  a  kitten  (  Pf oetchanstellung) .  The 
spasm  may  be  confined  to  the  hands  and  feet,  not  involving 
the  extremities. 

The  thighs  are  commonly  flexed  upon  the  belly  arid  the 
legs  may  be  upon  the  thighs.  The  feet  are  sharply  extended. 
They  may  be  in  the  position  of  equinovarus.  The  phalanges 
of  the  toes  are  flexed  up  to  the  second  and  third  rows,  which 
are  extended.  The  back  of  the  foot  becomes  very  promi- 


SYMPTOMS.  289 

nent,  and  gives  the  appearance  of  edema  on  account  of  its 
increased  convexity.  The  under  surface  of  the  foot  is 
arched. 

Tonic  contractions  may  involve  the  muscles  of  the  neck 
and  cause  the  infant  to  assume  the  position  of  opisthotonos. 
The  body  may  be  bent  forward,  on  the  other  hand — 
emprosthotonos.  The  muscles  o>f  the  forehead  are  com- 
monly involved  and  the  latter  may  therefore  be  wrinkled. 
The  mouth  may  be  puckered  ( Karpf enmund,  or  carp's 
mouth). 

Eclampsia,  or  convulsions,  occurs  in  infants  as  a  com- 
mon clinical  experience.  This  must  never  be  regarded  as  a 
distinct  disease,  but  merely  as  a  symptom  of  an  underlying 
cause  or  diathesis.  Where  organic  and  inflammatory  dis- 
ease of  the  nervous  system,  kidney  lesions,  and  epilepsy  can 
be  excluded,  careful  investigation  will  frequently  reveal  the 
presence  of  the  spasmophilic  diathesis.  As  will  be  detailed 
later,  this  fact  is  of  immense  importance  in  the  treatment 
of  convulsions,  especially  in  its  relation  to  their  prevention, 
and  sheds  much  new  light  upon  this  frequently  fatal  con- 
dition. The  convulsions  are  clonic  and  nearly  all  the  cases 
which  ordinarily  occur  in  childhood  must  be  included  under 
this  caption. 

Hard  Edema. — A  peculiar  swelling  of  the  hands  and 
feet  is  a  frequent,  although  not  a  constant,  accompaniment 
of  tetany.  It  is  not  a  true  edema,  as  pitting  does  not  occur. 
It  is  probably  a  vasomotor  disturbance  of  the  skin.  The 
hyperextensioti  of  the  feet  already  referred  to  assists  in 
causing  the  cushion-like  appearance  of  the  dorsum  of  the 
feet. 

Other  Symptoms. — Where  very  severe  generalized  in- 
volvement obtains,  retention  of  urine  and  obstinate  consti- 

19 


290  SPASMOPHILIA. 

pation  may  ensue  from  intense  spasm  of  the  sphincters.  In 
the  latter  instance  the  abdomen  may  become  much,  dis- 
tended. As  the  spasm  relaxes  there  occurs  a  discharge  of 
feces  and  of  gas,  and  the  distention  may  thus  suddenly  dis- 
appear. Lingual  and  esophageal  spasms  have  been  noted. 

The  pupils  are  contracted  and  do  not  respond  to  light. 
Nystagmus  and  strabismus  may  also  occur.  Spasm  of  the 
bronchi  may  appear  independently  of  all  other  features  of 
the  disease. 

The  clinical  picture  may  assume,  therefore,  the  ap- 
pearance of  pneumonia  (Lederer).  The  absence  of  physical 
signs,  temperature,  leucocytosis,  and  the  presence  of  the 
electrical  reactions  of  spasmophilia  or  of  the  facial  or 
other  reflex  phenomena,  will  permit  of  a  correct  differ- 
entiation. 

In  manifest  tetany,  we  may  encounter  vosomotor  dis- 
turbances involving  the  skin,  and  resulting*  in  urticaria,  ery- 
thema, profuse  sweating,  and  intense,  though  evanescent, 
edema  locally  situated  or  of  the  entire  body.  The  latter, 
upon  superficial  examination,  may  be  mistaken  as  due  to 
nephritis.  Digestive  disturbances  occur  both  in  cases  of 
latent  and  of  manifest  spasmophilia. 

Irregular  Forms. — Ihe  first  symptoms  may  appear  be- 
fore the  fourth  month.  The  order  of  the  appearance  of  the 
symptoms  may  be  reversed,  i.e.,  the  features  of  manifest 
tetany,  laryngospasmus,  and  of  the  electrical  reactions  or 
the  other  phenomena,  which  indicate  the  spasmophilic  basis, 
may  appear  before  the  characteristic  features  of  the  di- 
athesis are  in  evidence.  Sooner  or  later,  however,  these 
appear,  as  does  the  facial  phenomenon  of  Chvostek.  The 
diagnosis  is  sometimes,  therefore,  made1  with  difficulty,  and 
must  depend  upon  the  results  of  antispasmophilic  therapy. 


DIAGNOSIS  AND  DIFFERENTIAL  DIAGNOSIS.         291 

DIAGNOSIS  AND  DIFFERENTIAL  DIAGNOSIS. 

The  diagnosis  depends  upon  the  typical  symptoms  just 
detailed.  Of  greatest  importance  are  the  Chvostek  sign 
and  positive  electrical  reactions.  The  detection  of  latent 
spasmophilia  depends  largely  upon  a  study  of  these  two 
features  and  of  the  reflex  phenomena. 

The  discovery  of  the  latent  diathesis  really  constitutes 
the  crux  of  the  dagnosis,  for  it  is  distinctive  of  this  condi- 
tion alone  and  serves  to  properly  catalogue  the  symptoms 
of  manifest  tetany,  which  so  closely  resemble  Qther  diseases. 
These  need  but  be  mentioned,  for  in  all  a  study  of  the  re- 
flexes and  of  the  electrical  reactions  will  render  the  diag- 
nosis clear.  They  are  epilepsy,  cerebrospinal  meningitis, 
tetanus,  and  any  other  disease  in  which  irritative  or  con- 
vulsive symptoms  are  prominent  features.  Reference  has 
been  made  to  the  occurrence  of  a  positive  Chvostek  in  menr 
ingitis.  However,  this  need  cause  no  confusion,  as  other 
symptoms  and  the  information  provided  by  lumbar  punc- 
ture will  permit  of  a  correct  conclusion.  It  is  especially 
difficult,  in  some  cases,  where  a  knowledge  of  the  character- 
istic symptoms  of  spasmophilia  is  lacking,  to  say  that  a 
particular  child  has  or  has  not  epilepsy.  This  is  particularly 
true  of  those  brief  convulsive  attacks  associated  with 
momentary  loss  of  consciousness,  and  which  are  commonly 
precipitated  by  anger,  fright,  or  stubbornness,  and  which 
so  closely  resemble  petit  mal.  Stridor  inspiratorius  has 
already  been  considered.  Laryngospasmus  must  not  be 
confused  with  the  convulsive  stage  of  pertussis,  laryngeal 
diphtheria,  and  retropharyngeal  abscess.  Many  cases  of 
thymic  death,  so  called,  where  no  enlargement  of  the  thymus 
is  demonstrable,  are  undoubtedly  due  to  laryngospasmus. 


292  SPASMOPHILIA. 

PROGNOSIS. 

Where  recognized  and  promptly  treated,  the  outlook  for 
permanent  and  perfect  recovery  from  this  disease  is  ex- 
cellent. This  is  not  only  true  of  the  manifest  variety  but, 
with  equal  emphasis,  of  latent  spasmophilia.  Death  may 
unexpectedly  ensue,  in  an  otherwise  apparently  healthy 
child,  from  laryngospasmus  or  from  eclampsia.  Even  in 
mild  cases,  which  are  untreated,  complete  effacement  of  all 
evidences  of  the  diathesis  may  occur.  On  the  other  hand, 
in  these,  and  also  in  those  energetically  treated,  remains  of 
the  condition  may  persist  into  adult  life.  This  is  particu- 
larly true  of  Chvostek's  sign.  It  must  not  be  forgotten 
that,  under  any  exciting  factor,  the  latent  spasmophilia 
which  has  for  years  persisted  undetected,  may  be  speedily 
transformed  into  any  one  of  the  dangerous  expressions  of 
the  manifest  type,  and  with  a  fatal  outcome.  For  this 
reason  each  child  should  routinely  be  studied  at  least  for  the 
facial  phenomena,  if  search  for  the  electrical  reactions  be 
impossible. 

TREATMENT. 

Prophylaxis. — As  the  disease  is  not  found  in  breast-fed 
infants  it  logically  follows  that  every  effort  should  be  made 
to  conserve  the  maternal  milk.  If  this  fails,  properly 
directed  artificial  feeding  should  be  instituted  and  great  care 
exercised  to  prevent  overfeeding  and  consequent  digestive 
disturbances. 

Active  Treatment. — This  is  directed  toward  (a)  treat- 
ment of  the  diathesis  or  of  latent  spasmophilia  and  (b) 
treatment  of  the  symptoms  o>r  of  manifest  spasmophilia. 

(a)  Treatment  of  Diathesis. — This  is  accomplished  by 
proper  diet  and  carefully  directed  medicinal  treatment. 


TREATMENT.  293 

Most  cases  will  recover  if  placed  upon  breast  milk. 
Where  dependence  must  be  had  upon  artificial  feeding  it  is 
necessary  to  distinguish  between  those  babies  which  are 
being  overfed  and  those  which  are  underfed. 

Overfed  Babies. — A  hunger  period  should  be  instituted 
for  from  six  to  twelve  hours.  The  metabolic  processes  are 
thereby  rested  and  a  readjustment  of  the  infant's  organism 
is  permitted.  During  this  time  weak  tea,  sweetened  with 
saccharin  (gr.  j  to  I  quart),  alone  may  be  given.  Following 
this  a  5  per  cent,  solution  of  some  form  of  cooked  flour — 
wheat,  barley,  rice,  oatmeal,  or  arrowroot — is  administered 
for  eight  days.  Small  quantities  of  whole  milk  are  now 
judiciously  added,  commencing  with  about  50  grams  per 
diem.  This  is  mixed  with  the  flour  solution.  An  initial 
loss  of  weight  usually  occurs  and  is  of  no  consequence  if  not 
too  long  continued.  Therefore  the  daily  amount  of  milk  is 
cautiously  increased,  care  being  exercised  not  to  provoke  an 
acute  digestive  disturbance,  as  this  may  be  responsible  for 
the  appearance  of  an  attack  of  acutely  fatal  manifest  tetany, 
—for  instance,  laryngospasmus. 

Underfed  Babies. — A  hunger  period  is  here  decidedly 
contraindicated.  In  an  underfed  infant  an  acute  alimentary 
disturbance  must  be  overcome  as  quickly  as  possible. 
Where  gray,  constipated  stools  are  in  evidence  (Bilanzstoe- 
rung),  carbohydrate  is  lacking  in  the  diet,  and  its  addition 
favorably  influences  the  progress  of  the  case.  For  this 
reason,  these  cases  speedily  improve  on  malt-soup  or  butter- 
milk to  which  sugar  and  flour  have  been  added  (Chapter  III, 
page  123).  If  the  stools  and  weight  curve  indicate  chronic 
dyspepsia,  sugar  is  omitted.  Each  case  must  be  individual- 
ized. Intestinal  intoxication  calls  for  eiweissmilch  and  a 


294  SPASMOPHILIA. 

decomposition  must  be  treated  with  suitable  milk  mixtures 
or  breast  milk. 

Medicinal  Treatment. — The  best  remedy,  acting  prac- 
tically as  a  specific,  is  codliver  oil  combined  with  phos- 
phorus : — 

5  Phosphorus   I  centigram. 

Codliver  oil 100  grams. 

M.     Sig. :     f3j    administered   over   twenty-four   hours    and    in- 
creased to  f3iij. 

This  is  best  administered  one-half  hour  after  meals, 
If  the  stools  become  dyspeptic  the  oil  must  be  temporarily 
withheld.  The  good  effect  of  this  treatment  is  usually 
manifest  after  the  eighth  day.  Cure  is  often  effected  within 
three  to  four  weeks,  although  continuous  administration  of 
the  oil  and  phosphorus  must  be  practised  for  from  three  to 
four  months.  This  is  true  also  of  cases  placed  upon  the 
breast,  for  the  latter  alone  may  not  be  sufficient  to  produce 
a  disappearance  of  the  manifestations  of  latent  spasmophilia. 

In  some  very  mild  cases  which  are  receiving  cows'  milk, 
it  is  sufficient  simply,  in  conjunction  with  the  oil  and  phos- 
phorus treatment,  to  reduce  the  daily  amount  of  cows'  milk 
which  the  infant  is  receiving.  Thus,  if  this  be  800  grams 
per  diem,  it  may  be  reduced  to  400  grams  and  the  calories 
thus  lost  are  supplied  by  flour-gruels. 

(6)  Treatment  of  Manifest  Spasmophilia. — The  most 
important  symptoms  which  require  active  treatment  are: 
(a)  convulsions,  (&)  laryngospasmus. 

Convulsions. — Chloroform  is  not  recommended  by  the 
German  authorities,  although  in  America  it  is  almost 
routinely  employed.  When  judiciously  handled  it  produces 
beneficent  results  and  its  administration  mav  be  continued 


TREATMENT.  295 

cautiously  over  a  prolonged  period  of  time.  Of  late  the  best 
Continental  physicians  employ  calcium  bromid: — 

B  Calcium  bromid   10  grams. 

Aquae  destill 200  grams. 

M.    Sig. :  From  2  to  3  grams  (l/2  to  ^  dram)  to  be  administered 
daily. 

If  the  soporific  effect  be  too  persistent,  less  may  be  employed 
or  the  drug  may  be  temporarily  suspended. 

Though  not  as  valuable,  chloral  hydrate  may  be  substi- 
tuted for  calcium  bromid  if  this  chemical  is  not  to  be  had : — 

Chloral  hydrate   2  grams. 

Aquae    destill 100  grams. 

Ten  grams  of  the  solution  are  equivalent  to  0.2  gram  of 
chloral  hydrate.  This  is  administered  by  mouth  every  two 
hours  or  ^  gram  of  chloral  hydrate  may  be  employed  per 
rectum  as  follows: — 

Chloral  hydrate   i  gram. 

Gum-arabic    5  grams. 

Aquae  destill q.  s.  ad  50  grams. 

This  represents  two  doses.  Personally  I  favor,  and  have 
obtained  prompt  and  permanent  effects  from,  the  adminis- 
tration of  morphin: — 

Morphinae  sulph I  centigram. 

Aquae   destill 50  grams. 

One  fluidram  of  this  solution  equals  3  milligrams,  which  is 
the  dose.  The  best  effects,  however,  are  probably  secured  by 
administering  the  drug  hypodermically  in  the  dose  of  from 
V2oo  to  Vso  grain. 

Gastric  lavage  should  be  practised  if  the  history  indi- 
cates a  recent  dietary  indiscretion,  especially  if  sufficient 
time  has  not  elapsed  to  permit  the  food  to  have  passed  from 


296  SPASMOPHILIA. 

the  stomach.  While  the  tube  is  still  in  place,  if  the  child 
be  unconscious,  a  dose  of  castor  oil  may  be  administered  in 
this  manner.  On  the  other  hand,  a  dose  of  bromid  and 
chloral  may  also  be  given  in  this  way.  Colonic  irrigation 
should  be  practised  at  least  once.  In  other  words,  by 
mechanical  and  medicinal  means  it  should  be  positively 
ascertained  that  the  gastrointestinal  tract  has  been  thor- 
oughly cleansed. 

The  treatment  of  an  attack  of  laryngospasmus  differs 
in  no  important  essential  from  that  of  convulsions. 


CHAPTER  XI. 

EXUDATIVE  DIATHESIS. 

Definition  and  Nature. — To  the  German  pediatrists, 
especially  to  Czerny  (Berlin),  belongs  the  credit  of  crystal- 
lizing, under  this  term,  which  clearly  represents  a  disturb- 
ance of  metabolism,  an  ensemble  of  familiar  clinical  phe- 
nomena occurring  with  great  frequency  in  infants  and 
children.  The  condition  isi  characterized  by  the  frequent 
incidence  of  fibrinotis  or  exudative  inflammatory  processes 
i^'liich  attack  principally  the  skin  and  mucous  membranes. 
These  processes  appear  as  eczema,  and  as  catarrhal  involve- 
ment of  the  respiratory  and  gastrointestinal  tracts,  respect- 
ively. Many  of  these  patients  suffer  from  nervous  dis- 
turbances as  well.  The  lymphoid  tissues  may  exhibit 
chronic  enlargement.  Decided  interference  with  the  bodily 
nutrition  may  be  noted  in  some  cases. 

ETIOLOGY. 

Predisposing  Factors. — Although  not  manifesting  itself 
immediately  after  birth,  in  all  cases  the  condition  is,  in  all 
likelihood,  congenital.  The  exudative  diathesis  itself  is  a 
latent  process.  It  is,  as  it  were,  a  foundation  upon  which  in- 
fection is  easily  implanted  and  rapidly  develops.  Thus,  while 
the  various  evidences  of  inflammatory  disease  of  the  skin  and 
mucosse  constitute  an  essential  portion  of  the  clinical  picture 
of  the  condition,  they  in  themselves  are  not  entirely  due  to 
the  diathesis.  Without  infection  brought  to  the  parts  by 
carelessness,  accident,  or  filth,  they  could  not  occur.  It  is 
maintained,  however,  that  without  the  presence  of  the 

(297) 


298  EXUDATIVE   DIATHESIS. 

underlying  diathesis,  the  infection  would  not  develop. 
Thus,  a  reciprocal  relation  existing  between  the  diathesis 
and  the  infection  brings  the  manifestations  of  the  disease 
into  existence.  To  further  elucidate  this  point  it  may  be 
stated  that,  according  to  the  German  idea,  infections  of  the 
human  body  occur  in  two  ways,  viz.,  (a)  enteral  infection 
and  (b)  par  enteral  infection.  The  former  means  the  en- 
trance of  the  infective  agent  through  the  intestines  and  is 
represented  by  typhoid  fever,  amebic  dysentery,  etc.  The 
latter  represents  the  entrance  of  the  infection  through 
avenues  other  than  the  intestinal  tract;  for  instance, 
through  the  skin,  as  represented  by  eczema  and  erysipelas, 
and  through  the  respiratoiry  tract,  as  represented  by 
laryngitis,  bronchitis,  and  pneumonia.  It  is  largely  through 
these  parenteral  infections  that  the  exudative  diathesis 
becomes  manifest.  In  other  words,  it  is  the  predisposing 
factor.  Some  parenteral  infections  may  even  cause  other 
manifestations  of  the  diathesis,  already  present,  to  improve, 
while  others  intensify  the  symptoms.  Of  the  first  instance 
we  have  an  example  in  the  beneficent  effect  of  an  attack  of 
measles  upon  eczema,  and,  of  the  second,  it  is  well  known 
that  vaccinia  and  varicella  will  accentuate  the  symptoms  of 
this  disease.  Therefore,  unless  the  circumstances  be  un- 
usually urgent,  an  infant  with  eczema  should  not  be  vac- 
cinated. It  may  be  surmised,  correctly,  that  there  exists  a 
resemblance  between  the  clinical  behavior  of  the  exudative 
diathesis  and  that  of  spasmophilia.  The  latter,  as  we  have 
seen,  may  be  latent  and  becomes  manifest  only  as  the  result 
of  some  eotciting  factor. 

The  association  of  the  exudative  diathesis  with  spas- 
mophilia occurs  with  some  frequency  in  the  same  patient. 
The  relationship  is  not  clear.  The  event  is  probably  a  co- 


ETIOLOGY.  299 

incidence,  although  the  underlying  factor  in  each  instance 
is  metabolic. 

Heredity  undoubtedly  plays  a  role  of  importance. 
Many  children  of  the  same  parents  present  the  symptoms 
of  this  diathesis.  The  parents  themselves,  more  or  less 
constantly,  present  evidences  of  perverted  metabolic  proc- 
esses. They  are  frequent  victims  of  neurasthenia  or  of 
some  neurotic  manifestation,  or  suffer  from  lithemia,  the 
so-called  uric  acid  diathesis,  rheumatism,  diabetes,  asthma, 
acidosis,  indicanuria,  or  chronic  skin  affections.  Environ- 
mental influences,  however,  may  explain  these  results  as 
well  as  heredity,  as  the  disturbances,  evident  in  the  parents, 
may  be  due  to  dietetic  and  other  determining  factors  which 
are  permitted  to  operate  constantly  in  the  case  of  the 
offspring. 

The  disease  is  not  confined  to  those  artificially  reared, 
the  evidences  of  eczema,  especially,  occurring,  with  much 
frequency,  in  the  breast-fed. 

Unhygienic  surroundings,  as  already  intimated,  consti- 
tute a  predisposing  factor  of  no  mean  importance.  There- 
fore poverty,  ignorance,  overcrowding,  and  filth  in  every 
form  must  be  considered.  For  this  reason,  too,  the  disease 
is  more  common  in  the  city  than  in  the  country. 

Exciting  Factor. —  The  exact  cause  is  not  known.  Be- 
tween pediatrists  and  dermatologists  there  exists  a  differ- 
ence of  opinion  as  to  whether  the  skin  manifestations  are 
constitutional  or  local.  The  latter  view  is  held  by  the  der- 
matologists, who  proclaim  the  futility  of  any  but  local 
treatment.  The  proper  solution  will,  no  doubt,  determine 
that  both  local  and  constitutional  causes  are  operative. 
There  undoubtedly  exists  a  reciprocal  relation  between  the 
underlying  diathesis  and  infection.  Upon  what  does  the 


300  EXUDATIVE    DIATHESIS. 

diathesis  depend?  As  yet  this  has  not  been  clearly  defined. 
Czerny  regards  a  disturbance  in  the  fat  metabolism  as  the 
underlying  factor,  but  is  unable  to  exactly  describe  the 
nature  of  this  disturbance.  On  the  other  hand,  Finkelstein 
inclines  toward  the  view  that  the  error  lies  with  the  water 
and  with  the  salts.  This  finds  some  confirmation  in  the 
fact  that  certain  breast-fed  babies,  who  are  gaining  but 
slowly  and  who  have  eczema  intertriginosum,  are  benefited 
by  feeding  to  them  the  finely  comminuted,  coagulated  pro- 
tein of  cows'  milk,  with  salt,  in  addition  to  giving  them  the 
breast. 

In  this  instancei  the  fat  will  not  have  been  removed 
from  the  diet.  Finkelstein  also  suggests,  as  a  possible  cause, 
a  disturbance  in  the  nitrogen  metabolism  in  which  too  little 
nitrogen  is  absorbed.  In  any  event  it  may  be  stated  that 
somewhere  in  a  perverted  metabolism  lies  the  cause  and 
somewhere  in  diet  lies  the  cure,  because  all  cases  are 
decidedly  benefited  by  changes  in  the  food  andl  in  the  ex- 
ternal surroundings. 

Because  of  the  enlargement,  of  the  lymphatic  glands, 
not  infrequently  met,  the  relationship  existing  between  this 
condition  and  the  status  lymphaticus  has  been  considered, 
but  the  connection  is  not  clear. 

SYMPTOMS. 

In  order  to  attempt  some  form  of  classification  these 
will  be  discussed  under  (a)  body  weight,  (b)  skin  manifes- 
tations, (c)  respiratory  phenomena,  and  (d)  digestive 
symptoms.  It  is  important  to  emphasize  that  both  treated 
and  untreated  cases  vary  in  their  severity  throughout  the 
course  of  the  attack,  and  apparently  without  the  influence 
of  external  agencies.  One  set  of  symptoms  will  often 


SYMPTOMS.  301 

ameliorate  while  another  set,  hitherto  quiescent,  will  become 
intensified.  The  occurrence,  therefore,  of  substitution 
phenomena  is  a  part  of  the  natural  clinical  picture  of  the 
disease.  Thus,  the  skin  symptoms  may  entirely  disappear, 
to  be  followed  by  an  attack  of  asthma  or  digestive  disturb- 
ance, and  these  in  their  turn  will  be  succeeded  by  an  attack 
of  eczema. 

Body  Weight. — Two  types  of  patients  are  affected : 
Underfed  babies  and  overfed  babies.  It  is  important  to  dis- 
tinguish these  two  types,  as  experience  has  shown  that, 
originating  from  this  premise,  two  different  lines  of  die- 
tetic management  are  necessary  to  secure  good  results. 
Reference  will  again  be  made  to  this  classification.  In 
general  it  may  be  stated  that  the  underfed  baby  is  thin, 
puny,  and  "transparent,"  is  stationary  in  weight,  and  likely 
to  suffer  from  digestive  disturbance  and  diarrhea.  It 
often  suffers  from  eczema  seborrhceicum  universale,  with 
intertrigo. 

The  overfed  infant  appears  fat  and  robust.  These 
babies  are,  however,  commonly  anemic,  have  poor  resist- 
ance, and  exhibit  the  wet  forms  of  eczema,  especially  of  the 
face  and  head.  They  also  have  more  or  less  digestive  dis- 
turbance and  may  be  constipated. 

Skin. —  The  dermal  phenomena  may  be  classified  as 
neuropathies,  eczemas,  pruriginous  inflammations,  and 
strophnhis. 

The  first  are  seen  as  increased  vasomotor  irritability  and 
exhibit  themselves,  not  uncommonly,  as  alternate  flushing 
and  paling  of  the  surface,  without  apparent  cause.  This 
gives  rise,  at  times,  to  the  diagnosis  of  anemia  (pseudo- 
anemia),  an  examination  of  the  blood  showing  its  hemo- 
globin content  to  be  normal.  Fugitive  erythemas,  itching, 


302  EXUDATIVE    DIATHESIS. 

exanthemas,  pruritus,  urticaria,  and  dermographia  consti- 
tute the  more  common  remaining  skin  neuropathies. 

The  eczemas  are  usually  found  during  the  first  year. 
Frequently  they  develop  during  the  first  weeks  and  even 
days  of  life.  They  rarely  last  beyond  the  end  of  the 
second  year.  Two  principal  types,  of  which  there  are  sev- 
eral variations,  exist:  Eczema  seborrhoische  universale, 
or  universal  seborrheic  eczema,  and  eczema  of  the  face  and 
head.  The  latter  may  occur  with  the  universal  type. 

Eczema  Seborrhoische  Universale. — This  develops  as  a 
consequence  of  increased  epidermal  desquamation,  and  ex- 
hibits white  or  yellow  scales  which  are  more  or  less  filled 
with  inspissated  sebaceous  matter.  It  may  appear  upon  the 
head  and  forehead  and  about  the  temples  and  eyebrows,  or 
it  may  become  diffuse  and  cover  the  entire  body  with 
scaling  plaques.  The  oily  nature  is  best  noted  upon  the 
scalp  on  account  of  the  abundance  of  oil-glands  in  this 
situation.  On  the  body  cracks  or  fissures -occur,  and  from 
these  exude  serum  and  blood  which  dry  and  form  crusts. 
The  covering  of  the  scalp  may  be  a  complete  mask  in  which 
the  hair  is  matted  in  an  untangleable  mass  (gneisz). 

A  form,  in  which  the  scalp  is  simply  covered  with  more 
or  less  oily  scales,  but  in  which  the  underlying  skin  is  not 
inflamed,  also  occurs.  Removal  of  the  crust  reveals  only  a 
pale  surface  and  there  is  no  bleeding.  This  is  known  as 
seborrhea  capitis.  Itching  is  slight.  On  the  other  hand, 
should  the  skin  beneath  be  red  and  angry,  and  itching  be 
intense,  then  true  seborrheic  eczema  is  present.  This  is  a 
dry  type  of  eczema,  and  rarely  is  severe. 

Intertrigo,  or  eczema  intertriginosum,  in  nearly  all  cases 
follows  or  accompanies  eczema  seborrhceicum.  It  is  the 
same  process  except  that  it  is  found  in  the  folds  of  the  skin, 


SYMPTOMS.  303 

particularly  at  the  joints,  in  the  front  part  of  the  neck,  and 
in  the  groins  and  behind  the  ears.  The  last  is  an  especially 
common  situation.  In  the  groin  it  must  not  be  confounded 
with  simple  maceration  and  slight  irritation  of  the  skin  re- 
sulting from  acid  stools  and  urine  and  carelessness.  This 
type  is  moist,  while  eczema  intertriginosum  is  frequently 
dry  and  the  skin  is  always  infiltrated  or  thickened  and 
readily  cracks.  It  may  be  mild  or  severe.  These  infants 
are  often  weak  and  under  weight,  and  have  mild,  dyspeptic 
stools. 

Closely  resembling  this  type  of  eczema  is  erythrodermia 
desqiiamativa,  or  Leiner's  disease  (Vienna).  Finkelstein 
and  Moro  regard  them  as  identical.  Rarely  eczema  inter- 
triginosum becomes  infected  with  the  diphtheria  bacillus, 
when  it  assumes  the  clinical  features  of  this  disease. 

Eczema  of  Face  and  Head. — This  type  occurs  most 
commonly  after  the  fourth  month.  Careful  observation 
will  detect  its  presence  almost  at  its  inception.  All  infants 
with  "red  cheeks"  should  be  objects  of  suspicion.  Nor- 
mally the  cheeks  of  infants  are  not  red.  They  possess  the 
healthy  skin  color.  This  is  true  also  out-of-doors.  In  this 
type  of  eczema  there  is  seen  a  more  or  less  circumscribed 
area  of  redness  on  one  or  both  cheeks.  At  first  glance,  and 
always  to  the  untrained  eye,  it  may  appear  as  the  blush  of 
health. 

The  skin,  however,  will  be  observed  to  be  somewhat 
inelastic,  at  times  shiny,  and  to  be  covered  with  very  fine 
scales.  It  itches  but  slightly,  as  a  rule.  The  process  may 
be  stayed  in  its  further  development.  Later  papules  may 
appear  and  itching  may  become  so  intense  that  the  infant 
unmercifully  tears  its  own  flesh,  causingi  it  to  bleed.  Crusts 
are  formed  and  infection  is  not  uncommon.  Many  of  these 


304  EXUDATIVE   DIATHESIS. 

babies  are  transformed  into  pitiful  sights,  and  suffer  in- 
tensely from  the  scratching  and  tearing  and  crust  formation. 
If  their  hands  are  tied  they  bury  their  heads  into  the  pillow 
or  nib  them  against  any  object  in  their  frenzy  to  secure 
relief.  Removal  of  the  crusts  (milk  crusts,  or  crustalactea} 
is  followed  by  bleeding.  The  skin  of  the  rest  of  the  body 
may  appear  quite  normal. 

Sometimes,  instead  of  papules,  vesicles  appear  (eczema 
vesiculosum}  or  their  place  may  be  taken  by  pustules 
(eczema  vacciniformis).  This  differs  from  eczema  vac- 
cinatum,  which  is  due  to,  and  occurs  around  the  area  of, 
vaccination. 

Phlyctenular  conjunctivitis  and  keratitis  impetiginosum 
are  regarded  by  Czerny  as  eczema  of  the  cornea,  They 
occur  in  weak,  anemic,  underfed  infants,  and  place  a  grave 
prognosis  upon  the  final  outcome  of  the  disease.  Heubner 
and  Finkelstein  deny  the  relationship  of  this  condition  to  the 
exudative  diathesis. 

Pruriginous  Inflammations. — The  staphylococci  which 
normally  inhabit  the  skin  may  become  pathogenic,  as  a  re- 
sult of  the  lowered  resistance  due  to  the  exudative  diathesis, 
and  thus  be  responsible  for  pruriginous  inflammatory  proc- 
esses. The  most  common  expressions  of  this  condition  are 
furtmculosis,  ecthyma,  and  infected  pemphigus. 

Strophulus. — This  appears  in  older  infants  and  children 
as  a  rule.  It  resembles  urticaria  in  the  sense  that  the  lesions 
may  appear  as  wheals.  They  are  not  as  evanescent,  how- 
ever. More  often  they  occur  as  simple  small  papules  on  the 
apices  of  which  appear  minute,  deep-seated  vesicles.  The 
lesions  occur  anywhere  on  the  body,  most  often,  however, 
on  the  extremities  and  buttocks.  They  itch  intensely  and 
seriously  interfere  with  the  child's  rest.  If  the  minute 


SYMPTOMS.  305 

vesicle  is  punctured  the  degree  of  itching  is  decidedly 
ameliorated.  They  are  made  decidedly  worse  by  filth. 

Respiratory  Symptoms. — Catarrhal  involvement  of  the 
respiratory  mucosa  is  a  cardinal  feature  of  the  exudative 
diathesis.  A  tendency  toward  recurrence  of  these  attacks 
is  their  most  significant  characteristic  (the  so-called  "re- 
current sibilant  bronchitis"  of  American  writers).  Rhinitis 
is  common  as  well  as  pharyngitis  and  follicular  tonsillitis 
and  chronic  tonsillar  cnlarge^nent.  Bronchitis,  which  not 
only,  as  just  stated,  frequently  recurs,  but  which  is  likely 
to  become  subacute  or  chronic,  is  constantly  seen.  These 
frequent  infections  are  no  doubt  responsible  for  the  many 
children  who  present  enlargements  of  the  submaxillary  and 
cervical  lymphatic  nodules.  The  majority  of  these  enlarge- 
ments are  probably  tubercular.  This  is  true  also  of  the 
enlargements  so  commonly  found  at  the  roots  of  the 
bronchi.  Infection  in  both  instances  is  the  result,  undoubt- 
edly, of  the  frequent  "colds"  to  which  patients  with  the 
exudative  diathesis  are  subject.  This  disease  therefore  be- 
comes one  of  considerable  importance  in  the  consideration 
of  the  prophylaxis,  not  only  of  glandular,  but  of  pulmonary 
and  of  all  other  types  of  tuberculosis. 

"Bronchial  asthma,"  or  recurrent  sibilant  bronchitis, 
to  which  reference  has  already  been  made,  a  disease  but 
little  understood  as  to  its  etiology  and  certainly  less  so  as  to 
its  therapeutics,  is  regarded  by  the  Germans  as  being, 
especially  in  infants  and  young  children,  a  neuropathic 
expression  of  the  exudative  diathesis  affecting  the  bronchial 
mucosa.  Right  or  wrong,  it  matters  little  as  long  as  a  new 
thought  with  reference  to  this  vicious  and  puzzling  malady 
is  suggested.  The  diet  therefore,  as  indicated  later,  should 
be  intelligently  handled.  Perhaps,  then,  this  disease  may 

20 


306  EXUDATIVE    DIATHESIS. 

offer  another  example  of  a  serious  affection  yielding  to  a 
simple  remedy  which  has  long  been  close  at  hand,  but  which 
has  remained  unrecognized. 

Digestive  Symptoms. — Lingua  geographica  (-Fig.  47)  is 
a  dominion  occurrence  and  is  prima  facie  evidence  of  the 
presence  of  the  diathesis.  It  is  a  thickening  of  the  epithelium 
covering  the  tongue,  and  assumes  the  form  of  a  whitish 
elevation  which  changes  in  shape  from  day  to  day.  Oral 


Fig.  47. — Lingua  geographica. 

infections,  as  stomatitis  and  canker,  likewise  occur.  The 
breath  is  heavy  and  often  has  a  sweetish  odor.  The  bowels 
are  commonly  normal,  but  may  be  constipated.  The  thin, 
dyspeptic  stools  of  the  newborn,  breast-fed  baby  are  re- 
garded by  Czerny  as  due  to  this  diathesis.  My  own  experi- 
ence would  lead  me  to  believe  that  this  is  not  so  in  the 
majority  of  instances.  The  intestinal  mucus  may  reveal 
eosinophiles  (eosinophilous  stools).  Dyspeptic  stools  are 
commonly  met  in  the  weak,  underfed  infants  who  suffer 
from  eczema  intertriginosum. 


DIAGNOSIS  AND  DIFFERENTIAL  DIAGNOSIS.         307 

The  Blood  and  Nervous  System. — Some  of  these,  babies 
exhibit  symptomatic  anemia.  In  most  all,  the  cosinophiles 
arc  increased  to  as  high  as  from  20  to  30  per  cent.  Espe- 
cially is  this  noted  in  cases  with  eczema.  The  connection  is 
not  clear.  Whether  the  eosinophilia  depends  upon  the 
eczema,  or  both  the  eczema  and  the  eosinophilia  depend  upon 
the  underlying  factor,  has  not  been  determined.  Various 
nervous  symptoms  appear  from  time  to  time,  as  night- 
terrors,  chorea,  urinary  incontinence,  etc.  These  are  not  to 
be  regarded  as  the  direct  manifestations  of  the  diathesis,  but 
occur  from  other  exciting  factors  operating  upon  a  weakened 
system. 

DIAGNOSIS  AND  DIFFERENTIAL  DIAGNOSIS. 

From  all  that  precedes,  the  physician  will  immediately 
recognize  that  he  has  seen,  and  is  seeing  daily,  many  of  these 
infants  and  children.  In  the  past  he  has  failed  to  classify 
them,  failed  to  recognize  that,  without  a  correct  conception 
of  the  underlying  diathesis,  his  attempts  to  thoroughly  cure 
these  babies  of  eczema  and  other  infections  have  been  sig- 
nally fruitless.  On  the  other  hand,  he  has  succeeded  blindly, 
applying  his  remedies  empirically,  but  without  the  stimulat- 
ing effect  upon  himself  which  comes  from  doing  things  for 
a  reason.  Granting  that,  even  with  the  recognition  of  the 
exudative  diathesis  as  a  clinical  entity,  much  concerning 
its  intimate  nature  remains  lacking,  we  are  at  least  provided 
with  a  basis  for  correct  reasoning.  Consequently  with  an 
attempt  toward  a  correct  therapeutic  regime  we  are  rewarded 
in  some  very  obstinate  cases  with  brilliant  results.  There 
remains  nothing  from  \vhich  it  is  necessary  to  distinguish 
this  diathesis. 


308  EXUDATIVE    DIATHESIS. 

PROGNOSIS. 

As  before  stated,  the  severity  of  the  manifestations  of  the 
diathesis  varies  constantly  without  the  influence  of  external 
agencies.  The  substitution  phenomena  already  mentioned 
must  be  borne  in  mind.  Eczemas  are  rarely  fatal,  although 
they  may  be,  especially  in  the  presence  of  severe  secondary 
infection.  I  have  seen  fatal  pyemia  result.  The  outlook 
in  respiratory  conditions  depends  on  their  severity  and  fre- 
quency and  the  general  condition  of  the  patient.  The  pos- 
sibility of  tubercular  infection  must  be  remembered.  Fre- 
quent attacks  of  follicular  tonsillitis  lead  to  chronic  hyper- 
trophy and  cardiac  disease.  The  possible  extension  o>f  the 
effects  of  the  diathesis  into  adult  life,  in  the  shape  of  rheu- 
matism, eczema,  gout,1  diabetes,  asthma,  and  other  affec- 
tions of  undoubted  metabolic  origin,  is  not  at  all  unlikely. 

TREATMENT. 

Prophylaxis. — A  change  from  the  city  to  the  seashore  or 
to  the  country  is  of  supreme  value  in  hastening  the  cure. 
The  utmost  cleanliness  should  be  observed  in  handling  the 
eczemas.  Even  without  any  evidences  of  skin  involvement 
the  latter  should  in  every  way  be  thoroughly  cleansed, 
properly  dried,  and  protected  from  infection  and  filth.  The 
proper  care  of  anal  and  urinary  discharges  is  particularly 
important.  I  have  learned  to  appreciate  the  value  of  daily 
inunctions  of  cold  cream  for  purposes  of  cleanliness,  instead 
of  water,  in  cases  where  the  skin  exhibits  the  least  irritation 
or  is  already  involved. 

Underfed  Infants  with  Eczema  Intertriginosum  and 
Eczema  Universale. — In  the  breast-fed  it  is  necessary  to 
add  protein  and  salt  to  the  diet.  For  this  purpose,  while 
continuing  the  breast,  either  plain  sodium,  chlorid,  15 


TREATMENT.  309 

grams  daily,  are  given,  or  the  same  amount  of  "emsersalz" 
(equal  parts  of  NaCl  and  NaHCO3).  This  is  given  with 
Larosan  or  Nutrose.  The  former,  as  previously  stated,  is 
calcium  casein  and  the  latter  is  sodium  casein.  These  prep- 
arations are  added  to  water  or  diluted  milk,  in  which  the  salt 
is  also  placed.  They  may  be  sweetened  if  necessary  with 
saccharin.  They  are  given  for  every  other  feeding.  Locally 
fullers'  earth  is  applied  to  the  skin  lesion  with  very  good 
effect. 

In  artificially  fed  children  who  are  under  weight,  reduce 
the  fat  and  feed  the  child  with  eiweissmilch  or  Larosan 
made  up  with  milk,  whole  or  diluted.  After  the  dyspeptic 
stools  become  normal  a  formula  low  in  fat  and  containing 
starch-  or  a  cereal-  water  or  gruel  may  be  substituted. 

Locally  if  the  lesions  are  at  all  moist  the  application  of 
fullers'  earth  is  followed  by  a  happy  effect.  On  the  other 
hand,  the  preparations  of  tar  serve  well  in  many  instances. 
In  seborrhcea  capitis  nothing  does  quite  so  well  as  a  thor- 
ough cleansing  with  tincture  of  green  soap,  each  morning, 
subsequent  to  the  application  of  the  following  for  twenty- 
four  hours : — 

Ac.   salicylic gr.  vj-x. 

Ung.  aquae  rosae  or  lanolin   Sj. 

Under  the  influence  of  this  simple  ointment  the  cracks  of 
eczema  seborrhceicum  and  of  eczema  intertriginosum  speed- 
ily disappear  and  the  infiltrated  areas  are  made  softer,  less 
thick,  and  more  pliable. 

Overfed  Children  with  Eczema  of  Head  and  Face. — 
In  these  cases  the  total  amount  of  food  must  be  reduced  as 
well  as  the  quantity  of  fat  and  carbohydrate.  These  chil- 
dren should  be  fed  almost  exclusively  on  a  diet  consisting  of 
vegetables,  cereals,  and  eggs.  Some  children  exhibit  an 


310  EXUDATIVE    DIATHESIS. 

intolerance  for  egg-albumin  and  are  made  worse  thereby. 
This  may  be  determined  in  some  cases  by  performing  a  test 
upon  the  skin  exactly  as  the  von  Pirquet  tuberculin  reaction 
is  done,  except  that  egg-white  is  rubbed  into  the  scarifica- 
tion instead  of  tuberculin.  If  the  child  is  sensitive  to  this 
form  of  protein  an  area  of  erythema  will  surround  the  scari- 
fication upon  which  the  substance  was  deposited  (Allergy). 
Very  little,  if  any,  milk  should  be  given.  With  some  babies, 
even  eggs  must  be  omitted.  If  milk  is  used  at  all,  it  is  best 
given  skimmed.  In  the  dry  forms  of  eczema  the  ointment 
above  detailed  is  of  service. 

The  wet  types  of  eczemas  do  well  on  eczema  soup,  which 
must  be  administered  for  from  four  to  eight  weeks.  This 
soup  is  made  as  follows:  Coagulate  i  litre  of  milk.  Allow 
the  whey  to  thoroughly  drain  off.  Finely  comminute  the 
curd  by  pushing  it  through  a  hair-mesh  sieve.  Add  it  to 
200  grams  of  whey  and  further  add  sufficient  water  to  make 
i  litre,  and  sweeten  with  i  tablespoonful  of  cane-sugar  or 
i  grain  of  saccharin. 

Marked  amelioration  is  invariably  noted  after  the  ad- 
ministration of  this  preparation  for  just  one  week.  It  is 
well  now  to  make  use  of  additional  carbohydrate  and  some 
vegetables  and  a  cereal.  Spinach,  mashed  carrots,  stewed 
celery,  stewed  onions,  oatmeal,  farina,  and  cream  of  wheat 
are  examples  of  the  types  of  food  to  be  allowed.  The 
extra  carbohydrate  should  consist  of  either  cane-sugar  or 
some  preparation  of  malt-sugar. 

Locally,  when  the  eczema  becomes  dry,  a  tar  ointment 
should  be  employed. 

Czerny,  besides  recommending  a  change  in  climate, 
orders  the1  following  regime  for  a  child  weighing  8 
kilograms : — 


TREATMENT.  311 

A.M. — A  simple  biscuit  cooked  in  100  grams  of  milk. 

Forenoon. — 200  grams  of  whole  milk  and  thin  oatmeal- 
gruel,  half  and  half. 

Xoon. — Soup  and  vegetables. 

Afternoon. — 200  grams  of  whole  milk  and  thin  oatmeal- 
gruel,  half  and  half. 

P.M. — 100  grams  of  whole  milk,  thickened  with  cereals. 
In  severe  cases  the  milk  may  be  still  further 
reduced. 

Recurrent  Bronchitis. — It  has  been  possible  in  several 
instances  to  cure  and  to>  prevent  a  recurrence  of  attacks  of 
bronchitis,  associated  with  dyspnea  and  sibilant  rales,  by 
adopting  the  following  routine:  In  the  beginning  milk, 
butter,  and  sugar  are  entirely  excluded  from  the  diet. 
Dependence  is  placed  entirely  upon  vegetables,  cereals,  and 
meats  ivi-thout  fat.  Raw  and  stewed  fruits  are  not  "per- 
mitted. Sweetening  is  obtained  by  the  use  of  saccharin. 
The  bowels  are  kept  regular  by  enemas  and  by  mineral  oil. 
All  external  sources  of  irritation,  whether  physical  or 
psychical,  are  avoided.  An  open-air  existence  must  be 
secured,  and  regular  bathing,  provided  there  be  no  eczema, 
must  be  practised.  Very  gradually  the  forbidden  articles 
of  food  are  added  to  the  diet,  one  at  a  time.  At  the  first 
suggestion  of  a  recurrence,  however,  they  are  again  rigidly 
excluded.  It  has  been  possible  to  demonstrate  almost  abso- 
lutely the  influence  of.  diet  upon  the  recurrence  of  attacks, 
in  several  instances,  and  in  others  it  has  been  possible  to 
demonstrate  the  negligible  effect  of  season.  Certain  chil- 
dren who  have  each  winter  suffered  from  recurrent  bron- 
chitis have  been  kept  entirely  free  when  the  diet  has  been 
rigidly  enforced. 


312  EXUDATIVE    DIATHESIS. 

Supposing  that  the  metabolic  disturbance  results  in  an 
acidosis  from  the  effects  of  which  the  bronchitis  arises,  the 
use  of  from  i  to  2  drams  of  bicarbonate  of  soda,  scattered 
throughout  the  food  each  day,  has  been  practised  with  good 
effects.  Other  alkalies,  like  potassium  or  sodium  acetate  or 
citrate  or  sodium  salicylate,  are  commonly  administered  in 
conjunction  with  the  dietary  treatment.  During  an  attack, 
use  is  sometimes  made  of  small  doses  of  tincture  of  bella- 
donna, with  good  effect. 


CHAPTER  XII. 
PYLORIC  OBSTRUCTION. 

Synonyms. —  Congenital  pyloric  stenosis,  Congenital  hy- 
pertrophic  pyloric  stenosis,  Pylorospasm,  etc. 


Fig.  48. — Showing  pyloric  obstruction. 

Nature. —  In  order  that  this  affection  may  be  the  better 
understood  it  appears  to  me  that  the  synonyms  above  should 
be  omitted  from  medical  literature  and  that  the  disease 
should  be  known  as  (a)  infantile  pyloric  obstruction  com- 
plete and  (b)  infantile  pyloric  obstruction  incomplete.  In 
all  cases  there  is  an  obstruction  at  the  pyloric  ring 
(Fig.  48).  This  prevents  the  onward  movement  of  the 
gastric  contents  into  the  duodenum  from  taking  place,  either 
completely  or  incompletely,  depending  upon  the  degree  of 

(313) 


314  PYLORIC   OBSTRUCTION. 

obstruction.  With  this  conception,  a  better  understanding 
of  the  clinical  phenomena  is  available  and  a  more  rational 
therapeutic  classification  is  also  possible,  as  we  shall  see. 

PATHOLOGY  AND   ETIOLOGY. 

Predisposing  Factors. — Age,  sex,  neurotic  parental  tem- 
perament have  all  been  studied  statistically  as  to  their  bear- 
ing on  this  condition,  but  they  serve  no  purpose  in  either 
prevention  or  in  cure,  and  will  not,  therefore,  be  further 
discussed. 

Active  Factors. — The  cause  of  the  obstruction  in  every 
case  is  a  narrowing  or  a  practical  obliteration  of  the  lumen 
of  the  pylorus  by  (a)  hypertrophy  of  the  pyloric  muscle  or 
(6)  spasm  of  the  pyloric  muscle  or  (c)  a  combination  of 
both  hypertrophy  and  spasm.  The  last  is,  ini  all  likelihood, 
most  commonly  present.  Bearing  these  underlying  anatomic 
features  in  mind,  it  is  perfectly  easy  to  understand  the  suc- 
cession of  symptoms  characteristic  of  the  two  types  of  this 
affection,  which  are  met  clinically.  Reference  will  again  be 
made  to  this  point. 

Much  as  a  clear  understanding  as  to  the  ultimate  direct 
cause  of  the  hypertrophy  or  of  the  spasm,  would  assist  in 
adopting  perhaps  antenatal  or  postnatal  preventive  meas- 
ures or  even  curative  ones,  at  present,  no  definite  data  bear- 
ing on  this  point  are  available  for  practical  purposes, 
although  many  theories,  ingenious  and  otherwise,  have  been 
offered.  These  I  shall  not  discuss,  for  a  medley  of  diverg- 
ent opinions  cannot  possibly  serve  any  useful  purpose  and 
will  only  yield  confusion.  My  view,  based  upon  the  obser- 
vation of  two  dozen  or  more  cases,  is  that  in  essentially  all 
of  them  the  initial  condition  was  spasm,  and  that  hyper- 
trophy followed  as  the  result  of  intense,  continuous  muscular 


PATHOLOGY   AND   ETIOLOGY.  315 

activity,  and  I  am  beginning  to  feel  that  perhaps  something, 
either  in  the  mother's  milk  or  in  the  intestinal  and  gastric 
juices  or  in  the  resultant  of  the  activity  between  these  juices 
and  the  milk,  is  responsible  for  the  initial  spasm.  There- 
fore T  believe  that  our  investigations  in  the  future  as  to  the 
fundamental  cause  of  the  primary  spasm  will  have  to  be 
sought  in  this  direction.  My  reasons  for  this  belief  are: 
(a)  most  cases  do  not  show  symptoms  immediately  after 
birth,  but  perhaps  anyivherv  from  two  to  four  ^veeks;  (b) 
the  degree  of  spasm  is  not  always  the  same  in  a  single  case, 
indicating  that  the  local  irritant  of  the  nervous  mechanism 
of  the  pylorus  varies  in  its  intensity;  (c)  complete  non- 
operative  recovery  is  possible,  the  symptoms  of  obstruction 
sometimes  subsiding  with  comparative  suddenness  and  this, 
in  some  cases,  has  been  hastened  by  a  change  in  diet.  For 
our  purpose,  at  present,  it  is  sufficient  to  remember  that  the 
pylorus  is  either  completely  or  partially  obstructed,  and  that 
either  one  of  these  conditions  may  be  brought  about  by 
spasm,  hypertrophy,  or  both.  Thus  it  is  conceivable  that  the 
spasm  may  be  so  intense  and  permanent  as  to  cause  complete 
obstruction,  just  as  well  as  one  may  imagine  a  partial  ob- 
struction due  to  hypertrophy  alone  (rare)  if  the  hyper- 
trophy were  not  sufficient  to>  entirely  occlude  the  lumen. 
Hypertrophy  per  se  may  cause  complete  obstruction.  So, 
too,  the  spasm  may  be  intermittent  when  either  alone  or 
combined  with  hypertrophy,  causing  the  obstruction  to  be 
intermittently  complete  and  incomplete.  Clinically  we  shall 
see  that  this  is  well  borne  out.  Thus  any  combination  erf 
spasm  and  hypertrophy  may  exist.  The  essential  thing, 
however,  as  far  as  subsequent  treatment  is  concerned,  is  to 
study  these  cases  clinically,  disregarding  in  a  sense  the 
pathology,  and  to  determine  in  the  individual  case  whether 


316  PYLORIC    OBSTRUCTION. 

the  obstruction  be  complete  or  incomplete  and,  if  the  latter, 
whether  enough  food  passes  to  sustain  life  and  to  warrant  a 
continuance  of  non-surgical  treatment.  Reasoning  from 
these  data,  the  symptomatology  may  be  rationally  discussed 
as  follows: — 

SYMPTOMATOLOGY. 

A.  Complete  Obstruction. — This  is  the  less  common  of 
the  two  varieties.  Vomiting  results  directly  from  the  ob- 
struction. The  food  cannot  get  through  the  obstructed 
pylorus,  so  it  is  ejected  through  the  cardia,  after  remaining 
in  the  stomach  a  variable  length  of  time.  It  is  the  latter 
phenomenon  which  often  causes  confusion  and  error.  One 
might  imagine  that  if  the  pylorus  is  completely  occluded  the 
vomiting  must  occur  after  each  feeding.  This  is  not  so 
because  the  stomach  becomes  dilated  and  its  capacity  may 
become  enormous  (Plate  XIII).  Thus  vomiting  may  occur 
but  three  to  four  times  or  less,  per  diem.  Especially  is  this 
true  after  the  condition  has  existed  some  weeks.  Therefore, 
the  amount  vomited  is  important.  It  may  represent  three  or 
four  or  five  or  more  feeds,  and  be  sour  and  bad-smelling. 
Vomiting  may,  however,  occur  after  each  feed. 

The  manner  in  which  the  food  is  ejected  is  characteristic. 
It  is  forceful,  propulsive,  projectile!  The  vomitus  literally 
shoots  out  of  the  mouth,  and  often  through  the  nostrils  as 
well.  If  very  acid  it  may  cause  the  infant  to  cry  or  set  up  a 
coryza.  The  stream  may  reach  a  foot  or  more  beyond  the 
crib.  It  occurs  without  nausea,  gagging,  or  any  apparent 
effort  on  the  part  of  the  infant.  Vomiting  may  commence 
immediately  after  birth.  More  often  it  is  delayed  until  the 
second  or  third  week.  It  is  one  of  the  prominent  causes  for 
removing  the  infant  from  the  breast  when  the  fault  lies  not 


PLATE  XIII 


H 


Showing  stomach-tube  in  situ  in  case  of  intense  gastric 
dilation.  The  tip  of  the  tube  is  opposite  the  right  superior  spine 
of  the  ilium  and  the  lower  border  of  the  stomach  is  at  the  brim 
of  the  pelvis.  This  case  made  a  complete  non-operative  re- 
covery. 


SYMPTOMATOLOGY. 


317 


with  the  maternal  milk,  but  depends  upon  an  unrecognized 
obstruction  at  the  pylorus.  The  further  history  of  these 
babies  usually  is  that  they  are  placed  upon  an  indifferently 


Fig.  49. — Weight  curve  in  a  case  of  complete  or  surgical 
pyloric  obstruction,  a-b,  continuously  downward  course  (char- 
acteristic of  this  type  of  obstruction),  resembling  the  crisis  of 
pneumonia  temperature  curve ;  b-c,  upward  course  (gain)  after 
posterior  gastroenterostomy.  (Original  case.  Operation  by 
John  B.  Deaver,  M.D.) 

modified  cows'  milk  or  upon  a  patented  food  without  any 
relief  from  the  vomiting1.  Such  a  history,  obtained  in  a 
breast-fed  baby,  should  always  create  the  suspicion  of 


318 


PYLORIC    OBSTRUCTION. 


pyloric  obstruction.  In  my  experience  it  has  been  so  con- 
stant that  I  have  come  to  regard  it  almost  as  a  part  of  the 
clinical  picture  of  the  disease. 

Constipation. — Think  again  of  the  pylorus  completely 
occluded,  either  from  spasm,  hypertrophy,  or  both.    All  the 


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Loss  of  Weight  during  period  of  observation  for  four  days  just 
preceding   operation 

Fig.  50  shows  effect  of  posterior  gastroenterostomy  on 
weight  curve  in  a  case  of  complete  pyloric  obstruction.  Note 
continuously  downward  course  of  weight  curve  before  opera- 
tion, as  in  Fig.  49.  Original  case.  Operation  by  Francis  T. 
Stewart,  M.D.  (H.  Lowenburg,  N.  Y.  Medical  Journal,  Feb- 
ruary 11,  1911.) 

food  is  vomited.  None  passes  into  the  duodenum  and 
thence  into  the  intestines.  The  reason  for  constipation  is 
clear.  It  is  complete — absolute.  It  is  obstipation.  The 
bowels  move  rarely,  it  is  true.  The  movements  consist  of  a 
discharge  of  bile-stained  mucus.  They  have  no  bulk.  They 


SYMPTOMATOLOGY. 


319 


contain  neither  curds  nor  digested-milk  feces,  because  none 
can  come  through. 

IVeiglii  and  Strength. — From  the  very  onset  of  symp- 
toms the  weight  curve  tends  progressively  downward.     It  is 


Fig.  51. — Visible  gastric  peristalsis. 

continuously  depressed.  There  is  no  hesitation,  no  retrench- 
ment, no  stationary  weight.  The  loss  may  not  be  suddenly 
great.  It  is  rarely  so.  It  is,  however,  continuously  down- 
ivard.  Thus  an  infant  weighing  7^2  pounds  at  birth,  for 
instance,  may  lose  y2  or  Y\  pound  by  the  end  of  the  first 
week  after  the  onset  of  symptoms.  If  this  is  repeated  dur- 


320  PYLORIC   OBSTRUCTION. 

ing  the  second  and  third  week,  the  possibility  of  complete 
obstruction  or  practically  complete  obstruction  becomes  a 
certainty.  The  weight  curve  in  these  cases  resembles  in  a 
sense  the  curve  seen  in  the  crisis  of  pneumonia  (Figs.  49 
and  50;  compare  with  Figs.  52  and  53).  The  effect  of 
edema  on  the  weight  curve  will  be  considered  later. 

The  infant's  strength  for  obvious  reasons  becomes  pro- 
gressively less.  Its  movements  become  weak;  its  cry  lacks 
force  and  it  lies  quietly  in  bed  unless  disturbed. 

Visible  Gastric  Peristalsis  (Fig.  51). — This  is  the  most 
interesting  as  well  as  the  most  important  symptom  from  a 
diagnostic  viewpoint.  Bearing  in  mind  ag'ain  the  obstruc- 
tion at  the  pylorus  (Fig.  48),  its  method  of  production  is 
readily  understood.  The  stomach  endeavors,  as  it  were,  to 
pass  its  contents  onward  into  the  duodenum.  It  cannot  do 
so.  This  causes  the  peristalsis  of  the  stomach  to  become 
exaggerated.  The  involuntary  muscle  is  stimulated  in  an 
effort  to  overcome  the  obstruction.  The  waves  of  contrac- 
tion become  greater  and  are  seen  in  the  epigastrium,  pass- 
ing from  left  to  right.  A  globular  mass  which  can  be  pal- 
pated will  appear  under  the  lower  left  costal  margin.  It 
will  lazily  pass  across  the  epigastrium.  Before  it  progresses 
very  far  another  will  form  at  the  original  site  and  slowly 
follows  the  first,  which  gradually  disappears  under  the  right 
costal  arch,  while  perhaps  yet  a  third  is  forming  under  the 
left  border.  So  it  will  be  seen  that  two  or  three  globular 
masses  are  slowly  following  one  another  from  left  to  right 
across  the  epigastrium.  The  appearance  has  been  likened  to 
the  rolling  of  two  or  three  balls  under  the  skin.  The  masses 
represent  sections  of  the  contracting  stomach. 

The  gastric  peristalsis  is  not  constantly  visible.  In  the 
beginning  it  may  not  be  seen  at  all  because  emaciation  has 


PLATE  XIV 


Practically  complete  obstruction.    Operation.    Recovery.    Imme- 
diately after  the  administration  of  the  bismuth. 


PLATE  XV 


One  hour  after  the  administration  of  the  bismuth.     Xone  of 
the  chemical  has  left  the  stomach. 


PLATE  XVI 


Three  hours  later.  Xo  bismuth  has  left  the  stomach.  Note 
the  thickened  pylorus  (P)  and  how  the  bismuth  shadow  stops 
abruptly  there. 


PLATE  XVII 


Six  hours  later.  Xo  bismuth  has  left  the  stomach.  Note 
the  stomach  was  photographed  while  undergoing  contraction 
(C).  Note  the  lower  border  of  the  stomach  to  be  opposite 
the  brim  of  the  pelvis.  Xo  bismuth  has  passed  beyond  the 
thickened  pylorus  (P). 


PLATE  XVIII 


The  next  day,  about  nineteen  hours  later.  Bismuth  still  in 
the  stomach.  Very  little  in  the  small  intestines  and  sigmoid. 
The  amount  is  practically  negligible.  Infant  has  vomited  some 
of  the  bismuth. 


PLATE  XIX 


Comet-like  appearance  of  the  bismuth  shadow  at  the  pylorus 
in  cases  of  complete  obstruction.  This  appearance  is  almost 
constant  and  is  very  characteristic  of  this  type  of  obstruction. 


SYMPTOMATOLOGY.  321 

not  become  sufficiently  advanced  to  permit  the  movement  to 
alter  the  normal  appearance  of  the  surface  of  the  upper 
abdomen.  It  may  also  be  invisible  when  the  stomach  is 
empty,  as  immediately  following1  a  severe  spell  of  vomiting-. 
Just  preceding  this  event,  however,  it  is  commonly  accen- 
tuated. It  is  often  present  during  sleep.  It  may  be  in- 
augurated by  tlie  giving  of  food  or  drink  or  by  tapping 
lightly  upon  the  epigastrium  ztrith  tJie  back  of  the  middle- 
finger.  A  few  moments  may  elapse  before  the  contractions 
commence  to  appear.  Therefore,  when  searching  for  this 
symptom  it  is  unsafe  to  conclude  that  it  is  absent  unless  the 
maneuvers  above  are  employed  and  unless  the  epigastric 
area  be  visualised  at  least  for  from  ten  to  fifteen  minutes. 

In  some  cases  the  pain  associated  with  the  contractions 
is  so  intense  as  to  cause  the  infant  to  cry. 

Rarely  the  movement  of  the  visible  gastric  peristalsis  is 
seen  to  be  reversed,  i.e.,  it  passes  from  right  to  left.  All 
these  instances,  however,  must  be  carefully  distinguished 
from  visible  peristalsis  due  to  contraction  of  the  transverse 
colon.  This  is  occasionally  met  in  thin  subjects  and  in 
cases  of  obstinate  constipation  or  of  organic  obstruction  of 
the  large  intestines. 

Dilated  Stomach. — At  first  the  muscle-fibres  undergo 
hypertrophy.  Later  they  become  thinned  and  the  degree  of 
gastric  dilation  may  become  enormous  (Plate  XIII).  As  a 
rule  the  lower  border  of  the  stomach  may  be  readily  seen 
through  the  thin  abdominal  wall.  At  first  it  does  not  reach 
below  the  umbilicus,  and  the  upper  abdomen  alone  is  dis- 
tended while  the  lower  portion  of  the  belly  is  flat  on  account 
of  the  collapsed  condition  of  the  intestines,  into  which  no 
food  has  entered.  Later  as  the  dilation  increases  the  lower 
border  of  the  stomach  reaches  far  below  the  navel.  In  fact 

21 


322  PYLORIC   OBSTRUCTION. 

it  may  reach  the  pelvic  brim  (Plate  XIII).  This  is  readily 
determined  by  inspection  and  can  be  confirmed  by  palpation 
and  X-ray  studies.  In  this  enormous  degree  of  gastric 
dilation  is  found  the  explanation  why,  in  advanced  cases 
especially,  vomiting  need  not  and  does  not  occur  after  each 
feeding  and  may  appear  but  a  few  times  each  day. 

Palpable  Pylorus. — The  pylorus  is  thick  and  hard 
(Fig.  48)  ;  whether  from  hypertrophy  or  from  spasm  or 
both,  matters  not.  The  abdominal  wall  is  thin.  Therefore 
it  is  possible  to  palpate  the  pylorus.  It  is  commonly  felt  as 
a  hard  object,  about  the  size  of  a  small  olive,  a  little  above 
and  to  the  right  of  the  umbilicus.  It  is  best  felt  by  placing 
the  warm  hand  gently  upon  the  abdomen,  employing  the 
middle-finger  as  a  searcher  by  gently  but  firmly  pressing  it 
into  the  abdominal  wall.  If  the  abdominal  muscles  are 
made  rigid  by  crying  or  straining,  palpation  cannot  be  suc- 
cessfully accomplished.  In  order  to  overcome  this  the  ex- 
amination should  be  made  while  the  infant  is  placed  at  the 
breast,  or  while  it  is  receiving  other  food  or  drink,  or  some- 
times during  sleep.  The  abdominal  wall  must  be  thoroughly 
relaxed. 

In  some  cases  of  complete  obstruction  it  is  impossible  to 
palpate  the  pylorus  during  the  early  stages  of  the  case  on 
account  of  the  comparatively  thick  layer  of  adipose  tissue, 
only  slight  or  no  loss  of  weight  having  occurred.  The 
position  of  the  pylorus  is  not  always  constant.  It  is  occa- 
sionally found  close  to  the  lower  border  of  the  liver,  near 
the  median  line,  but  above  the  umbilicus.  Where  a  great 
amount  of  gastric  dilation  has  ensued  it  may  be  found  low 
down  and  close  to  the  pelvic  brim  to  the  right  of  the  median 
line. 


SYMPTOMATOLOGY.  323 

X-ray  Studies. — These  should  be  made  in  all  cases. 
While  unnecessary  for  a  clinical  diagnosis  of  obstruction, 
per  se,  they  aid  materially  in  distinguishing  complete  from 
incomplete  cases,  and  are  often  of  lvalue  in  assisting  to 
determine  whether  the  treatment  shall  be  surgical  or  non- 
surgical.  For  making  these  studies  only  bismuth  subcar- 
bonate  should  be  employed,  and  should  be  administered 
through  a  tube.  In  cases  of  complete  obstruction  it  will  be 
found  that  no  bismuth  leaves  the  stomach  to  enter  the  in- 
testines, after  a  period  of  twenty-four  hours.  During  this 
time  a  series  of  no  less  than  eight  or  ten  exposures  should 
be  made,  commencing  immediately  after  the  administration 
of  the  drug  and  ending  not  less,  in  any  case,  than  sixteen 
hours  after  this  time.  This  will  insure  sufficient  time  to 
permit  the  smallest  amount  of  bismuth  to  pass  (Plates  XIV, 
XV,  XVI,  XVII,  and  XVIII). 

In  cases  of  complete  obstruction  I  have  noticed  that  the 
bismuth  shadow  assumes  a  "comet"-like  appearance  almost 
immediately  after  administration.  I  regard  this  as  highly 
significant  (Plate  XIX)  of  this  type  of  obstruction. 

Charcoal  Test. — Administer  10  grains  of  either  animal 
or  wood  charcoal  through  the  stomach-tube,  to  the  near  end 
of  which  is  attached  a  syringe  which  contains  the  charcoal 
suspended  in  an  ounce  or  two  of  water.  Slowly  inject  it. 
Make  a  note  of  the  hour  of  injection.  Have  the  nurse  do 
the  same,  each  time  she  changes  a  soiled  diaper.  In  cases  of 
complete  obstruction  no  charcoal  will  appear  upon  the 
diaper.  In  the  mean  time  considerable  charcoal  will  be  lost 
each  time  the  infant  vomits.  At  the  end  of  twenty-four 
hours  wash  out  the  stomach.  The  washings  will  contain 
charcoal — showing  conclusively  gastric  retention  and  the 
non-entrance  of  aliment  into  the  intestinal  canal. 


324  PYLORIC   OBSTRUCTION. 

Temperature. — This  speedily  becomes  subnormal  unless 
external  heat  is  employed.  If  infection  occur  it  becomes 
elevated.  These  infants  become  readily  infected  (see  Com- 
plications) .  When  starvation  becomes  marked  the  tempera- 
ture rises  and  may  reach  104°  F.  before  death.  I  have  also 
witnessed  a  sudden  rise  which  I  cannot  explain  follow 
immediately  after  stomach  washing-.  It  speedily  disappears, 
however.  The  poor  resistance  of  these  babies  is  frequently 
emphasized  by  their  death  from  pneumonia  just  about  at 
the  end  of  the  disease  or  immediately  after  recovery.  The 
temperature  rises  very  high  and  death  may  ensue  before  the 
signs  of  consolidation  become  evident. 

Urine. — The  urine  exhibits  no  changes  of  interest 
except  toward  the  end  in  cases  which  have  remained  un- 
treated and  in  which  vomiting  has  been  unduly  severe. 
The  tissues  become  parched  for  the  want  of  water.  The 
urine  then  is  scant,  dark,  highly  concentrated,  sharply  acid, 
and  excoriating.  Urates  may  be  deposited  upon  the  diaper. 
A  faint  trace  of  albumin  is  present  and  microscopically 
kidney  debris  and  other  organized  substances  are  found. 
Therefore,  other  things  being  equal,  it  may  be  correctly  sur- 
mised that  a  free  flow  of  normal  limpid  urine  is  a  favorable 
sign. 

Edema. — This  is  not  directly  a  part  of  the  clinical  pic- 
ture of  pyloric  obstruction.  It  may,  perhaps,  be  better 
classified  as  a  complication.  It  is  emphasized  here,  how- 
ever, because  its  onset  is  so  insidious  and  because  it  fre- 
quently passes  unnoticed,  but  principally  because  it  is 
responsible^  for  a  more  or  less  abrupt  increase  in  weight 
which  is  erroneously  regarded  as  a  favorable  sign.  The 
additional  weight  is  not  fat,  but  water.  I  have  seen  this 
error  made  and  a  favorable  prognosis  recorded  when  death 


SYMPTOMATOLOGY.  325 

was  but  a  few  days  away.  It  is  a  very  unfavorable  symp- 
tom. It  occurs  along  toward  the  end  of  severe  cases  in 
which  vomiting  has  been  unusually  constant.  The  insteps 
and  the  lower  legs  are  first  affected  and  gradually  it  spreads 
upward,  rarely,  however,  passing  above  the  knees.  Its 
method  of  production  is  little  understood,  notwithstanding 
an  overabundance  of  theorizing. 

B.  Incomplete  Obstruction. — This  type  is  more  common 
than  that  of  complete  obstruction.  There  are,  however,  all 
grades  of  this  form  which  clinically  must  be  differentiated. 
Many  of  them  approach  in  severity  cases  of  complete  ob- 
struction, as  we  shall  see,  and  must,  like  them,  be  treated 
surgically.  Therefore,  the  distinction  betwreen  complete 
and  incomplete  obstruction  must  not  be  regarded  as  final, 
but,  therapeutically,  at  least,  the  classification  of  surgical 
and  of  non-surgical  must  be  made  as  well,  for  many  cases 
of  incomplete  obstruction  require  operation.  In  fact,  I 
believe  the  number  of  this  type  of  case  is  daily  increasing, 
as  the  mortality  from  operations  is  steadily  becoming  less 
and  as  the  cases  are  receiving"  closer  clinical  study. 

Vomiting. — This  partakes  of  the  nature  of  the  vomiting 
in  cases  of  complete  obstruction,  except  in  very  mild  in- 
stances wherein  the  spasm  occurs  with  some  intermittency. 
Here  the  intervals  between  attacks  may  at  times  be  more 
than  a  day  or  two,  to  be  renewed  again  with  intense  vigor, 
when  the  degree  of  spasm  increases. 

Constipation. — Bearing  in  mind  again  the  obstruction 
at  the  pylorus  and  that  it  is  not  complete,  one  can  readily 
understand  that  some  of  the  aliment  passes  and  that  there- 
fore constipation,  while  present,  is  not  absolute.  The  size 
and  the  frequency  of  the  movements  vary  directly  as  the 
degree  of  obstruction,  which  also  determines  the  severity  of 


326 


PYLORIC   OBSTRUCTION. 


SYMPTOMATOLOGY.  327 

the  two  symptoms — vomiting  and  wasting.  These,  in  com- 
mon with  constipation,  form  a  trinity  of  symptoms  which  are 
closely  interrelated,  and  which  possess  considerable  prog- 
nostic import.  The  movements  are  usually  small  and  dry. 
Not  being  of  sufficient  size  to  stimulate  peristalsis,  they  lie 
in  the  lower  bowel  so  long  that  they  become  inspissated. 
The  bowels  move,  on  the  average,  once  every  three  or 
four  days,  a  suppository  or  the  clinical  thermometer  being 
necessary  to  secure  an  evacuation.  The  movements  consist 
of  milk  feces  and  mucus,  and  often  contain  small  curds 
which  in  themselves  are  conclusive  evidence  that  the 
pylorus  is  not  entirely  occluded. 

Weight  and  Strength. — A  common  clinical  type  o>f  in- 
complete obstruction  presents  a  weight  curve  which  is 
radically  different  from  that  of  complete  obstruction,  For 
developing  this  fact,  I  believe  that  I  may  claim  originality, 
for  I  have  no  knowledge  of  its  description  having  been  pro- 
posed by  any  other  author.  Before  describing  this  curve  it 
is  necessary  to  state  that  there  is  one  type  of  case,  however, 
of  incomplete  obstruction  of  which  this  is  not  true,  viz., 
those  instances  in  which  the  passage  through  the  pylorus 
is  so  small  that  but  little  aliment  passes,  and  for  all  intents 
and  purposes,  clinically  at  least,  the  case  presents  the  fea- 
tures of  complete  obstruction,  and  must  be  so  regarded 
therapeutically.  It  would  perhaps  be  better  to  say  that  this 
latter  type  of  weight  curve  belongs  to  surgical  cases  rather 
than  to  a  certain  type  of  incomplete  obstruction,  because 
all  cases  which  present  it  must  be  operated  upon  and  under 
it  are  included  as  well  all  cases  of  complete  obstruction,  as 
has  been  already  indicated  (Figs.  49  and  50).  Figs.  54 
and  55  represent  the  correct  manner  of  weighing  an  infant. 

The   curve   in    typical,    non-operative,    or   non-surgical 


328 


PYLORIC    OBSTRUCTION. 


incomplete  cases  suggests  the  line  of  a  continuous  fever 
with  slight  remissions  and  elevations  (Fig.  53;  compare 
with  Figs.  49  and  50).  Thus  the  infant  loses  a  few 
ounces, — say,  two  or  three.  The  next  day  he  gains  one 
or  two  ounces.  The  day  following  neither  loss  nor 
gain  is  recorded.  This  may  continue  for  a  day  or  two. 
Again  a  slight  gain  or  a  slight  loss  occurs,  so  that  at  the 


Fig.  54. — Weighing  the  baby.    First  ascertain  the  weight  of  the 
towel.     (Fairbank's  scale,  No.  554.) 

end  of  a  week  the  weight  is  the  same  or  there  is  noted  the 
loss  or  the  gain  of  an  ounce  or  two.  The  curve  may  remain 
stationary  for  two  or  three  weeks,  with  slight  losses  or 
gains  recorded  in  the  daily  estimations.  These  have  a 
direct  relation  to  the  severity  of  the  vomiting  and  the  con- 
stipation. If  spasm  is  worse  for  a  few  days,  these  are  in- 
creased and  with  them  is  recorded  a  loss.  As  the  obstruc- 
tion relaxes  vomiting  and  constipation  are  less,  and  the 
lost  weight  is  partially  or  wholly  regained,  with  an  ounce 
or  so  to  spare.  Therefore  it  can  be  appreciated  how  at  the 


SYMPTOMATOLOGY.  329 

end  of  five  or  seven  weeks  after  birth  the  weight  has 
changed  but  little,  being  somewhere  between  six  and  seven 
pounds,  or  there  may  be  noted  but  a  slight  loss  of  about  a 
half  to  three-quarters  of  a  pound.  A  careful  study  of  Figs. 
50  and  53  will  be  of  value  in  emphasizing  this  crucial 
clinical  point  of  difference  between  operative  and  non- 
operative  cases. 


Fig-  55- — From  combined  weight  of  baby  and  towel  subtract  the 
weight  of  towel  to  obtain  result. 

Visible  Gastric  Peristalsis. — The  description  of  this 
symptom  under  complete  obstruction  applies  here,  except 
that  at  times  the  intensity  of  the  waves  may  be  temporarily 
suspended  only  to  return  again  with  increased  vigor. 

Dilated  Stomach.— The  degree  of  dilation  is  somewhat 
less  than  in  complete  cases,  although  in  severe  types  it  may 
reach  to  enormous  proportions.  After  recovery,  in  non- 
operative  cases  too,  the  normal  outlines  of  the  stomach  are 
commonly  recovered  except  in  those  cases  which  extend 
into  childhood  and  to  which  reference  will  again  be  made. 


330  PYLORIC    OBSTRUCTION. 

Palpable  Pylorus. — The  same  causes  which  at  times  in- 
terfere with  the  successful  palpation  of  a  completely  oc- 
cluded pylorus  apply  here.  In  addition,  in  those  cases  which 
depend  entirely  upon  spasm  and  in  which  this  phenomenon 
is  intermittent,  even  when  the  abdominal  wall  is  quite  thin, 
the  pylorus  will  not  be  palpable  when  it  is  relaxed.  There- 
fore should  this  finding  be  reported  negatively  it  does  not 
exclude  the  diagnosis  of  either  pyloric  obstruction,  com- 
plete or  incomplete.  In  the  latter  instance  it  may  be  posi- 
tive the  next  day  or  within  a  few  hours  or  even  minutes. 
It  may  occur  as  the  visible,  gastric  peristalsis,  directly  after 
the  giving  of  food  or  drink  or  after  tapping  over  the  epi- 
gastrium, to  disappear  again.  The  fed  of  a  pylorus,  in 
spasm  is  just  as  hard  as  of  one  thickened  by  hypertrophy, 
only  it  may  not  be  so  constant.  For  this  reason  I  do>  not 
believe,  as  some  authors  teach,  that  every  case  in  which  the 
pylorus  is  palpable  should  be  operated  upon.  I  have  had 
several  non-surgical  recoveries  in  such  instances.  This 
intermiittency  is  very  common  in  partial  cases  and  is  sug- 
gestively diagnostic  of  them.  Where  hypertrophy  is  present 
or  where  spasm  is  intense  and  permanent,  this  intermittency 
of  palpability  may  be  absent  and  the  hard,  olive-like  pylorus 
may  be  easily  and  constantly  felt. 

X-ray  Studies. — These  indicate  that  more  or  less 
rapidly,  depending  upon  the  degree  of  obstruction,  varying 
amounts  of  bismuth  pass  from  the  stomach  into  the  intes- 
tines. The  quantity  which  does  pass  and  the  time  occupied 
furnish  valuable  data  in  assisting  to  determine  the  necessity 
for  or  against  operation  (Plates  XX,  XXI,  XXII,  XXIII, 
XXIV,  XXV,  XXVI,  XXVII,  XXVIII,  and  XXIX).  A 
careful  study  of  these  plates  will  indicate  that  cases  of  in- 


DIAGNOSIS  AND  DIFFERENTIAL  DIAGNOSIS.         331 

complete  obstruction,  may  be  either  surgical  (Plates  XXV 
to  XXIX)  or  non-surgical  (Plates  XX  to  XXIV). 

Charcoal  Test. — Charcoal  passes  through  the  pylorus 
and  is  therefore  found  in  the  feces.  The  stomach  washings 
contain  not  any,  little,  or  much  charcoal,  twenty-four  hours 
after  administration,  depending  upon  the  degree  of  obstruc- 
tion and  the  severity  of  the  vomiting.  Immediately  after 
administration  the  caretaker  is  instructed  to  save  and  mark 
the  time  of  each  soiled  diaper.  In  this  way  an  idea  is  ob- 
tained as  to  the  degree  of  obstruction  and  the  rapidity  of  the 
peristalsis.  Therefore  the  X-ray  findings  and  the  charcoal 
test  are  valuable  in  permitting  of  an  intelligent  separation 
of  the  surgical  from  the  non-surgical  cases. 

Temperature. — ^"here  the  degree  of  emaciation  is  ex- 
treme, the  temperature  is  subnormal.  However,  it  is  less 
difficult  to  maintain  a  rectal  temperature  of  982/5°  to  99°  F. 
than  it  is  in  complete  cases. 

Urine  and  Edema. — Neither  of  these  possesses  the  same 
interest  as  in  cases  of  complete  obstruction  unless  the  degree 
of  impatency  be  unusually  severe. 

DIAGNOSIS  AND  DIFFERENTIAL  DIAGNOSIS. 

A.  In  General. — Pyloric  obstruction  is  not  recognized 
because  the  average  physician  does  not  include  it  in  the 
range  of  possibilities  in  reference  to  every  case  of  wasting 
with  which  he  comes  in  contact.  He  does  not  think  of  it  at 
all.  Its  clinical  features  are  so  unique  that  it  cannot  be 
mistaken  for  anything  else  and  cannot  be  passed  by  if  it  is 
at  all  considered.  Nearly  every  case  of  unrecognized  pyloric 
obstruction  which  I  have  seen  in  consultation  has  been 
called  marasmus.  The  differentiation  has  already  been  dis- 
cussed under  the  description,  of  the  latter  (Chapter  IV, 


332  PYLOR1C   OBSTRUCTION. 

page  165).  It  is  of  sufficient  importance,  however,  to  em- 
phasize here  that  these  two  conditions  resemble  each  other 
only  in  so  far  that  in  both  wasting  is  a  prominent  feature. 
Wasting  in  infancy.,  however,  must  simply  be  regarded  as 
a  symptom  and  not  as  a  disease,  and  the  underlying  cause 
must  always  be  diligently  sought.  In  this  connection 
pvloric  obstruction  must  always  be  considered  as  a  very 
potent  and  probable  factor -of  the  nutritional  bankruptcy. 

A  very  common  occurrence  is  to  consider  that  the 
vomiting  is  due  to  the  breast  milk.  The  infant  is  then 
promptly  removed  from  it  and  a  medley  of  formulas  and 
patented  foods  are  employed  before  the  real  cause  of  the 
disturbance  is  discovered.  The  practical  constancy  of  this 
error,  as  forming  a  part  of  the  clinical  history  of  this  disease, 
has  already  been  considered.  For  ordinary  purposes  it  may 
be  stated  that  mother's  milk  never  causes  vomiting,  per  se, 
unless  the  amount  of  fat  is  unusually  high  for  the  individ- 
ual. More  often  among  benign  causes  of  vomiting  in  the 
suckling  it  will  be  found  that  too  frequent  feeding,  pro- 
longed nursing,  nervous  influences,  improper  training,  and 
bad  hygiene,  singly  or  combined,  are  operative.  Besides, 
the  character  of  the  vomiting  is  never  propulsive.  There- 
fore the  following  may  be  stated  as  a  truism:  That  every 
case  of  persistent  vomiting,  especially  if  projectile,  occurring 
in  a  breast-fed  baby,  must  be  regarded  as  due  to  obstructive 
pyloric  disease  until  it  can  be  proven  that  it  is  not. 

The  only  other  factor  responsible  for  projectile  vomit- 
ing is  cerebral  disturbance.  Here  a  history  of  dystocia  or 
forceps  pressure  or  visible  head  trauma  will  be  in  evidence, 
together  with  the  results  of  cerebral  pressure  or  irritation, 
as  coma,  palsies,  or  convulsions.  An  exception  to  the  last 
occurred  in  a  case  seen  at  the  Mt.  Sinai  Hospital,  in  which, 


DIAGNOSIS  AND  DIFFERENTIAL  DIAGNOSIS.         333 

following  a  history  of  forceps  delivery,  the  infant  suffered 
one  or  two  attacks  of  convulsions.  Vomiting  soon  super- 
vened, but  a  careful  physical  examination  revealed  all  the 
characteristics  of  pyloric  obstruction  incomplete.  This 
merely  emphasizes  the  need  of  bearing  pyloric  obstruction  in 
mind  in  every  case  of  vomiting  as  well  as  in  every  case  of 
wasting. 

Cyclic  Vomiting. — I  have  proven  to  my  awn  satisfac- 
tion, at  least  in  one  case  in  which  the  diagnosis  of  cyclic 
vomiting  had  been  made,  that  the  cause  of  the  periodic 
emesis  depended  upon  the  persistence  of  a  mild  intermit- 
tent pyloric  obstruction.  The  child  was  2*4  years  of  age. 
The  history  of  incomplete  pyloric  obstruction  in  infancy 
was  clear  and  X-ray  studies,  as  well  as  the  retarded  passage 
of  charcoal,  made  the  diagnosis  certain.  Therefore,  the 
suggestion  is  offered  that  all  cases  of  so-called  cyclic  vomit- 
ing in  young"  children  should  be  studied  from  this  stand- 
point before  they  are  regarded  as  being  idiopathic,  reflex,  or 
metabolic.  The  case  to  which  reference  has  been  made  re- 
covered completely  under  lavage. 

Obstipation  or  constipation,  occurring  as  the  result  of 
congenital  or  other  defects,  may  cause  some  confusion,  espe- 
cially if  there  be  associated  reflex  vomiting,  so  called. 
Bearing  in  mind  the  essential  symptomatology  of  pyloric 
disease,  an  intelligent  discrimination  will  readily  be  per- 
mitted. 

B.  Complete  Obstruction. — Depending  directly  upon  the 
complete  obstruction  at  the  pylorus,  the  following  ensemble 
of  symptoms  constitutes  a  definite  clinical  picture:  Propul- 
sive vomiting,  obstipation,  loss  of  weight  and  strength 
(persistent},  visible  gastric  peristalsis,  dilated  stomach,  pal- 
pable pylorus;  non-passage  of  bismuth  subcarbonate  from 


334  PYLORIC   OBSTRUCTION. 

the  stomach  into  the  intestines,  as  sho^mi  by  the  X-rays;  the 
non-passage  of  charcoal  through  the  gastrointestinal  canal 
and  its  recovery  the  next  day  in  the  stomach  washings. 

C.  Incomplete  Obstruction. — This  is  characterized  by 
propulsive  vomiting;  a  variable  degree  of  constipation;  a 
gradual  loss  in  iveight,  which  may  become  stationary; 
visible  gastric  peristaltic  waves  of  variable  intensity;  per- 
manently or  intermittently  palpable  pylorus;  dilated  stom- 
ach; the  retarded  but  final  passage  of  bismuth  through  the 
pylorus  into  the  intestines;  the  passage  of  charcoal  and  its 
non-return  or  in  variable  but  small  amounts  in  the  gastric 
it-askings,  depending  upon  the  degree  of  obstruction. 

By  noting  the  amount  of  bismuth  and  of  charcoal  which 
passes,  one  is  often  permitted  to  judge  of  the  quantity  of 
aliment  which  gets  through,  and  is  therefore  able  to  con- 
clude roughly  whether  this  is  sufficient  to  sustain  life.  This 
materially  assists  one  to  properly  catalogue  the  individual 
case  as  surgical  or  non-surg'ical.  The  differential  data  be- 
tween these  two  types  of  cases  are  systematically  presented 
under  the  prognosis,  page  338. 

COMPLICATIONS. 

Pneumonia  may  occur,  rarely,  as  a  direct  result  of  stom- 
ach washing,  due  to  inspiration  of  foreign  material.  These 
cases  all  do  poorly.  High  temperature,  difficult  to  explain, 
may  follow  stomach  washing.  As  has  been  mentioned,  it 
speedily  disappears.  Edema  has  been  noted.  These  in- 
fants, o<n  account  of  their  low  vitality,  bear  infection  badly. 
I  have  seen  a  severe  case  of  pyemia  follow  the  undoubted 
infection  of  bromid  papules.  The  eruption  was  profuse 
upon  the  scalp  and  face.  Under  the  administration  of  a 
mixed  streptococcic  and  staphylococcic  serobacterin  recovery 


PROGNOSIS.  335 

ensued.  Sudden  death  occurs  without  apparent  cause,  as  in 
cases  of  marasmus,  after  extreme  emaciation  has  persisted 
for  some  time. 

PROGNOSIS. 

In  general  this  depends  upon  the  promptness  with  which 
a  diagnosis  is  made,  and  with  which  an  intelligent  therapy 
is  adopted  and  conscientiously  pursued.  No  half-way 
measures  will  bring  results.  Cases  which  are  hawked  from 
doctor  to  doctor  or  from  clinic  to  clinic  eventually  succumb. 
For  this  reason  I  believe  that,  once  the  diagnosis  is  made, 
the  physician  should  make  a  frank  statement  of  the  case 
to  the  parents,  going  into  details  as  to  the  exact  nature  of 
the  trouble,  defining  his  attitude,  telling  them  at  best  the 
case  will  be  long  drawn  out,  and  that  at  any  time,  after  a 
sufficient  period  of  observation  has  elapsed,  it  may  become 
operative.  On  this  point,  I  believe  that  a  week's  observa- 
tion should  permit  of  an  intelligent  and  final  opinion. 

The  attention  to  details,  the  infant's  environment,  close 
adherence  to  prescribed  methods  of  treatment,  strict  loyalty 
to  feeding  orders,  are  all  of  unquestioned  importance  in  their 
bearing  upon  the  final  outcome  of  the  case. 

Of  course,  operation  increases  the  immediate  danger. 
However;  the  results  after  posterior  gastroenterostomy  have 
been  so  excellent  that  in  selected  cases  it  should  not  be  too 
long  postponed.  The  operation  must,  however,  be  done  by 
an  expert,  and  before  the  infant's  nutrition  and  strength  be- 
come too  seriously  impaired.  Even  as  a  derni-er  ressort  it 
must  not  be  refused,  in  cases  which  have  been  neglected. 
No  case  is  hopeless,  from  an  operative  standpoint,  until  it  is 
dead.  Scudder  and  others  report  brilliant  success  from 
operations.  My  own  operative  cases  include  six:  one, 
almost  moribund,  recovered  after  operation  by  Dr.  Francis 


336  PYLORIC    OBSTRUCTION. 

T.  Stewart.  Five  others  were  operated  upon  by  Dr.  John  B. 
Deaver:  four  made  excellent  recoveries;  one  died  twenty- 
four  hours  after  operation.  This  infant  was  edematous  and 
emaciated  when  brought  to  the  table,  where  it  nearly  suc- 
cumbed twice  during  operation.  Operation  had  been  ad- 
vised as  the  only  hope  two  weeks  previously,  but  was  re- 
fused. The  youngest  case  operated  upon  by  Deaver  was  3 
weeks  of  age.  It  made  a  perfect  recovery.  The  oldest, 
operated  upon  by  him  for  me,  was  8  weeks  of  age.  It  too 
became  well.  Sixty-three  per  cent,  of  my  medical  cases 
recovered.  Of  those  which  died  some  were  unrecognized 
until  it  was  too  late,  some  refused  surgical  treatment,  and 
still  others  were  entirely  neglected.  I  believe  that  if  the 
cases  treated  medically  are  properly  selected,  the  percentage 
of  recoveries  would  be  higher  and  would  equal  at  least  the 
operative  results.  The  idea  which  I  wish  to  convey  is  that 
in  our  study  of  this  disease  it  should  ever  be  our  aim  to  im- 
prove our  knowledge  as  to  the  character  of  a  non-operative 
and  of  an  operative  case.  The  line  of  distinction  can  be 
drawn,  and  I  believe  that  none  of  these  babies,  if  properly 
classified,  other  things  being  equal,  need  succumb.  Even 
recognising  that  operation  increases  the  immediate  danger, 
I  believe  that  this  risk  should  be  assumed  in  more  cases 
rather  than  to  err  on  the  side  of  attempting  to  treat  surgical 
cases  by  non-surgical  methods.  It  is  my  belief  that  the 
general  mortality  of  pyloric  obstruction  would  in  this  way 
be  more  materially  reduced  than  if  more  conservative 
methods  were  pursued. 

What  constitutes  a  surgical  case?  What  constitutes  a 
non-surgical  case?  Clinically  all  cases  become  operative 
when  sufficient  aliment  fails  to  reach  the  intestines.  There- 
fore it  follows  that  not  only  are  all  cases  of  complete  ob- 


PLATE  XX 


Non-surgical  incomplete  pyloric  obstruction.     Bismuth  in  the 
stomach  immediately  after  administration. 


PLATE  XXI 


Two  hours  later.    Much  bismuth  is  seen  in  the  small  intestine, 
but  also  in  the  stomach. 


PLATE  XXII 


Bismuth  still  in  stomach,  but  also  seen  in  small  intestine  and  in 
the  ascending  colon  ;  four  hours  after  administration. 


PLATE  XXIII 


Much  bismuth  still  in  stomach,  but  also  seen  in  the  descend- 
ing colon  and  sigmoid;  six  hours  after  administration.  Stomach 
should  be  empty. 


PLATE  XXIV 


Eighteen  hours  later.     Stomach   should  he  empty,  but 
still  contains  much  bismuth. 


PLATE  XXV 


Case  of  incomplete  but  surgical  pyloric  obstruction.  Gas 
and  bismuth  in  contracting  stomach,  immediately  after  ad- 
ministration. 


PLATE  XXVI 


Bismuth  in   stomach,  hut   small   amounts  scattered  throughout 
small  intestine :  two  hours  later. 


PLATE  XXVII 


Same  as  Plate  XXV,  four  hours  after  administration. 


PLATE  XXVIII 


Eight  hours  after  administration  of  bismuth.     Stomach  still 
full  and  very  little  bismuth  has  reached  colon. 


PLATE  XXIX 


^ 


Sixteen  hours  after  administration.  Stomach  full.  Still 
much  bismuth  in  stomach  and  very  little  in  large  intestine.  It 
can  readily  be  seen  that  if  this  represents  the  amount  of^food 
which  passes,  starvation  must  follow.  Compare  Plates  XXV  to 
XXIX  inclusive  with  Plates  XX  to  XXIV  inclusive. 


TREATMENT.  337 

struction  to  be  treated  surgically,  but  also  those  incomplete 
cases  in  which  the  degree  of  obstruction  is  so  great  and  so 
persistent  that  for  all  intents  and  purposes  they  may  be 
regarded  as  complete.  In  these  cases  the  amount  of  bis- 
muth which  passes  through,  representing  really  the  same 
amount  of  food,  is  negligible  and  certainly  is  not  sufficient 
to  maintain  tissue  balance,  let  alone  to  provide  for  growth 
as  well  (Plates  XXV  to  XXIX).  Therefore,  in  deciding 
the  issue,  the  character  of  the  weight  chart  is  of  prime  im- 
portance. My  study  of  many  cases  convinces  me  that  all 
operative  cases  will  show  a  weight  curve  represented  by 
Fig.  50,  and  that  all  non-operative  cases,  charts  like  Figs. 
52  and  53.  The  further  elucidation  of  this  important 
point  is  assisted  by  a  careful  study  of  the  X-ray's  findings, 
the  charcoal  test,  and  the  degree  of  constipation.  It  is 
important  to  emphasize  that  the  distinction  between  sur- 
gical and  non-surgical  cases  must  be  made  upon  clinical 
findings  alone,  and  not  on  the  cause  of  the  obstruction,  even 
were  this  always  determinate.  It  is  perfectly  conceivable 
that  simple  spasm  may  be  so  intense  and  so  persistent  as 
to  entirely  occlude  the  pyloric  orifice,  while,  on  the  other 
hand,  hypertrophy  may  occur  without  causing  even  as 
much  encroachment  upon  the  lumen.  In  order  to  facili- 
tate an  early  distinction  the  differential  table  on  next  page  is 

submitted. 

TREATMENT. 

At  present  this  is  either  surgical  or  non-surgical.  No 
preventive  methods  are  known. 

Surgical. — I  shall  not  discuss  the  surgical  treatment 
from  the  standpoint  of  technique.  This  has  been  ably  done 
by  Dr.  John  B.  Deaver.  The  province  of  the  physician,  I 
believe,  is  to  determine  whether  or  not  operation  should  be 

22 


338 


PYLORIC  OBSTRUCTION. 


DIFFERENTIAL  TABLE. 


NON-SURGICAL. 

1.  Weight      curve      resembles 
curve    of    continued    fever    with 
slight   remissions   and   elevations. 
At  end  of  week  it  is  stationary  or 
but  slight  loss  or  gain  is  recorded. 

2.  General  strength  not  mate- 
rially reduced  at  end  of  this  time. 


SURGICAL. 

1.  Weight  curve  resembles  the 
crisis  of  a  pneumonia.    End  of  a 
week  records  a  loss  of  8  to   10 
ounces  or  more. 

2.  General   strength   fails   rap- 
idly. 


3.  Bowels   constipated,   but   of  3.  Constipation      absolute      or 

fair  size,  and  movements  contain      nearly    so.     Milk    feces    may    be 

passed,  but  only  in  very  small 
amounts.  Movement  ordinarily 
consists  of  bile-stained  mucus. 

4.  Non-recovery  of  charcoal  in 
anal  discharges,  or  very  little,  and 
this    appears    first    thirty-six    to 
forty-eight  hours  later,  and  con- 
tinues for  many  days. 

5.  Recovery     of     considerable 
quantity  of  charcoal  in  the  stom- 
ach  washings   twenty-four   hours 
or     more     after     administration. 

6.  X-ray     pictures     taken     in 
series  for  a  period  of  twenty-four 
hours  show  retention  of  bismuth 
within  the  stomach,  and  not  any  or 
only  traces  in  the  small  and  large 
intestines.    Bismuth  shadow  has  a 
"comet-like"  appearance. 

7.  Constant.    Not  influenced  by 
gastric  lavage. 

8.  Constantly    palpable    except 
before  emaciation  occurs. 

9.  Nearly  all  hospital  cases  and 
those  in  which  the  environmental 
influences  are  bad  should  be  oper- 
ated upon  irrespective  of  the  de- 
gree of  obstruction. 


curds  or  digested  milk. 


4.  Recovery     of     considerable 
quantity  of  charcoal  in  anal  dis- 
charges,  although   its   passage   is 
delayed. 

5.  Non-recovery  or  recovery  of 
but  little  charcoal  in  the  stomach 
washings  twenty- four  hours  later. 

6.  X-ray  examination  confirm- 
atory   of    charcoal    findings    and 
character  of  the  constipation.    Re- 
veals more  or  less  bismuth  in  the 
small  and  large  intestines. 


7.  Severity     of     vomiting     is 
intermittent   and   often   yields   to 
gastric  lavage. 

8.  Pylorus  non-palpable  or  in- 
termittently so. 

9.  Intelligent  and  individual  care 
of  the  infant  at  home  may  delay 
or  permanently  eliminate  the 
necessity  for  operation  even  in 
severe  cases. 


TREATMENT.  339 

done.  This  must  not  be  left  to  the  surgeon  alone,  who,  as 
a  rule,  has  little  patience  with  less  rapid  methods  and  cer- 
tainly can  have  had  but  little  experience  in  handling  non- 
surgical  cases.  It  is  hoped  that  the  foregoing  discussion 
will  materially  assist  the  medical  attendant  to  reach  a  safe 
conclusion.  The  surgeon  must  decide  the  choice  of  opera- 
tion. In  all  of  my  cases  posterior  gastrojejunostomy  was 
performed.  The  results  have  been  so  satisfactory  that  I 
prefer  it.  I  believe  this  to  be  the  operation  of  preference 
with  most  surgeons.  Divulsion  has  been  recommended,  but 
it  seems  uncertain.  Simple  incision  of  the  pylorus  along 
its  longitudinal  axis  through  the  peritoneum  and  muscle, 
down  to  but  not  through  the  mucosa,  has  been  practised 
with  immediate  good  results.  No  sutures  are  taken  in  the 
pylorus.  The  circular  fibres  are  thus  severed.  The  lumen 
of  the  pylorus  becomes  patulous.  The  abdomen  is  imme- 
diately closed  and  the  wound  in  the  pylorus  is  allowed  to 
heal  by  granulation.  What  the  subsequent  life  of  such 
an  individual  would  be,  is  uncertain.  The  old  scar  may  cause 
considerable  trouble  through  further  contraction,  although 
theoretically  it  should  not.  This  operation  was  devised  by 
Ramstedt  and  is  recommended  by  E.  Feer  (Zurich).  A 
case  successfully  treated  in  this  manner  is  reported  from 
Koplik's  clinic  in  the  New  York  Medical  Journal.  As 
noted  below,  Dr.  Deaver  does  not  recommend  this  operation. 
What  is  the  subsequent  course  of  cases  operated  upon 
by  gastroenterostomy  ?  This  is  a  matter  of  pertinent 
interest.  Does  the  pylorus  become  patulous?  Does  the 
artificial  opening  enlarge  and  continue  to  functionate 
properly  throughout  adult  life?  Does  food  leave  the  stom- 
ach via  both  the  artificial  and  the  natural  routes?  These 
questions  are  difficult  to  determine  accurately.  I  believe 


340  PYLORIC   OBSTRUCTION. 

that  the  cause  of  the  obstruction  plays  an  important  part 
as  to  whether  the  pylorus  subsequently  becomes  patulous  or 
not.  Where  spasm  overshadows  the  amount  of  hyper- 
trophy, in  all  probability  food  will  again  pass  through  the 
pylorus.  Where  hypertrophy  is  the  main  factor,  permanent 
occlusion  is  most  likely.  In  all  the  cases  which  I  have  been 
permitted  to  study  with  the  X-ray,  after  operation,  the  arti- 
ficial opening  alone  was  functionating  and  the  pylorus  was 
still  impervious.  The  oldest  child  thus  studied  was  3^2 
years  of  age.  In  discussing  this  point  with  podiatrists  and 
surgeons,  it  appears  that  the  concensus  of  opinion  is  that 
this  represents  the  usual  course  of  events.  Further  skia- 
graphic  and  post-mortem  studies  are  necessary  to  determine 
this  with  accuracy.  Fig.  49  represents  the  effect  of  a  suc- 
cessful gastroenterostomy  upon  the  weight  curve  of  a  case 
of  complete  pyloric  obstruction. 

Postoperative  Treatment. — This  undoubtedly  should  be 
supervised  by  the  pediatrist.  Vomiting  may  persist  after 
operation  and  serious  diarrhea  may  occur.  I  have  also  seen 
severe  convulsions  in  a  case  with  continuous  bilious  vomit- 
ing. Ultimate  recovery  resulted.  Postoperative  vomiting 
may  be  due  to  the  regurgitation  of  bile  into  the  stomach  or 
it  may  result  from  postoperative  volvulus  of  the  proximal 
portion  of  the  small  intestine  used  in  making  the  anas- 
tomosis. Convulsions  may  likewise  result  from  the  entrance 
of  bile  into  the  stomach  and  its  absorption  from  the  gastric 
mucosa.  Therefore  gentle  stomach  washings  with  warm 
bicarbonate  of  soda  solution  may  be  instituted  twelve  to 
eighteen  hours  after  operation,  and  the  infant  may  be  sus- 
pended by  the  shoulders  in  an  upright  position.  Thus  by 
gravity  the  course  of  the  bile  is  assisted  in  taking  a  normal 
direction. 


TREATMENT.  341 

Small  quantities  of  diluted  human  milk  may  be  given 
either  through  the  tube  immediately  following  the  stomach 
washing  or  by  mouth,  using  a  medicine  dropper.  Twenty- 
four  hours  after  operation  regular  feedings  with  the  medi- 
cine dropper  should  be  instituted,  and  as  soon  as  the  infant 
is  sufficiently  strong  it  should  be  permitted  to  suck  the 
breast.  Where  breast  milk  is  unobtainable,  feeding  should 
be  inaugurated  with  weak  animal  juices,  to  be  followed  by 
whey,  pancreatized  formula,  or  very  weak  whole-milk  dilu- 
tions boiled  or  modified  by  Benger's  Food  or  by  flour  ball 
and  pancreatin. 

Diarrhea  may  be  controlled  largely  by  diet  and  by  the 
use  of  eiweissmilch  or  by  a  hypodermic  injection  of  morphin. 

To  combat  shock  immediately  after  operation,  hypoder- 
moclysis  of  normal  saline  solution  is  valuable,  or  the  water 
may  be  delivered  to  the  tissues  by  the  use  of  the  Murphy 
drip,  normal  saline  solution  containing  from  i  to  2  flui- 
drams  of  whisky  to  the  pint  being  employed. 

The  utmost  finesse  of  judgment  is  required  in  meeting 
the  postoperative  exigencies  which  arise.  Great  care  should 
be  exercised  not  to  do  too  much,  but  to  give  nature  a  chance 
to  adjust  herself  to  the  new  conditions.  The  feeding,  espe- 
cially if  artificial,  should  be  supervised  for  some  months 
following  operation,  for  gastrointestinal  upsets  may  bring 
serious  consequences. 

Non-surgical.— This  embraces  (a)  dietetic,  (b)  me- 
chanical, and  (c)  medicinal  measures. 

Dietetic. — In  the  beginning  these  cases  should  undoubt- 
edly be  kept  upon  the  breast  or  returned  to  it  if  the  mam- 
mary gland  is  still  functionating  sufficiently.  It  is  my  cus- 
tom always  to  take  the  mother  into  my  confidence  and, 
after  explaining  to  her  the  nature  of  the  case,  to  insist  that 


342  PYLORIC   OBSTRUCTION. 

her  full  co-operation  is  essential  to  a  successful  result.  Her 
nervousness  is  in  a  measure  overcome  and  a  steady  flow  of 
fairly  uniform  milk  is  thus  assured.  If  the  maternal  milk 
has  been  lost,  recourse  must  be  had  to  a  wet-nurse,  if  this 
be  possible.  In  some  communities  and  under  some  condi- 
tions the  services  of  these  women  cannot  be  obtained.  In 
one  case  I  received  daily  a  small  complement  of  milk  from 
four  different  mothers,  living  in  widely  separated  sections 
of  Philadelphia.  This  was  carried  to  the  house,  where  it 
was  mixed  together,  diluted  with  water,  and  fed  to  the 
infant  with  either  a  medicine  dropper  or  through  a  bottle. 
This  was  continued  until  a  satisfactory  wet-nurse  was 
secured.  The  beneficiary  of  these  four,  good,  unselfish 
women  is  now  a  robust  boy  of  over  3  years.  Whatever 
method  of  feeding  is  adopted,  it  is  important  to  insist  upon 
strict  regularity.  In  my  experience  short  meals  lasting  two 
to  three  minutes  given  every  hour  are  better  tolerated  than 
when  the  long-interval  feeding  of  large  meals  is  adopted. 
Vomiting  is  sometimes  lessened  by  feeding  the  breast  milk 
through  a  medicine  dropper,  or  it  may  be  slowly  injected 
by  means  of  a  small  syringe  before  removing  the  catheter 
directly  following  a  stomach  washing.  Vomiting  is  some- 
times remarkably  controlled  by  this  maneuver  when  it  con- 
stantly follows  feeding  by  sucking  either  the  bottle  or  the 
breast.  After  feeding,  the  infant  should  lie  upon  its  right 
side  to  favor  the  rapid  emptying  of  the  stomach. 

Where  the  breast  is  not  available  we  must  depend  upon 
artificial  feeding.  Whey  may  be  tried  for  a  while.  If  it 
agrees,  very  small  amounts  of  whole  or  of  skimmed  milk 
or  even  cream  may  be  added,  after  carefully  heating  the 
whey  in  order  to  prevent  coagulation  of  the  added  milk  or 
cream  (Chapter  III,  page  120).  I  have  seen  some  cases  do 


TREATMENT.  343 

well  on  a  highly  diluted  condensed  milk.  This  contains 
very  little  protein  and  fat  and  considerable  sugar,  which 
readily  furnishes  the  heat  which  these  infants  require  so 
badly.  If  the  stomach  contents  be  sour  and  highly  acid,  any 
of  these  substances  or  even  the  milk  mixtures,  to  which 
reference  will  be  made  presently,  may  be  largely  diluted 
with  lime-water  up  to  50  per  cent,  of  the  entire  diluent 
employed.  It  may  assist  in  controlling  vomiting.  Where 
ordinary  milk  formulas  are  employed,  large  doses  of  sodium 
citrate  (see  later)  are  useful  to  prevent  coagulation  of  the 
milk  in  the  stomach. 

I  believe  that  simple  dilutions  of  whole  or  of  skimmed 
milk  to  be  as  useful  as  any  of  the  more  elaborate  modifica- 
tions. Especially  is  this  true  if  the  mixture  be  boiled  or  if 
Benger's  Food  or  flour  ball  and  pancreatin  be  employed  to 
modify  the  curd  and  to  assist  in  the  digestion  of  the  fat. 
High  dilutions  are  at  first  employed,  I  to  2  ounces  in  20  of 
diluent.  This  should  either  be  barley-water  or  oatmeal- 
water,  or  plain  boiled  water  or  a  mixture  of  equal  parts  of 
the  cereal-water  and  boiled  water.  The  last  is  usually  to 
be  preferred.  Lime-water  may  be  substituted  for  any  of 
these.  To  the  formula,  modified  either  by  Benger's  Food 
or  by  flour  ball,  sodium  citrate  may  in  addition  be  added. 
Small  doses  of  the  formula  are  given  often.  Gradually  the 
strength  of  the  mixture  is  increased. 

Additional  carbohydrate  is  furnished  by  either  cane- 
sugar  or  by  some  preparation  of  maltose,  as  Mead-Johnson's 
Dextri-Maltose  or  Loeflund's  Food  Maltose.  In  these  cases 
I  prefer  the  malt-sugars,  on  account  of  their  rapid  absorb- 
ability. They  maintain  body  temperature  and,  I  believe, 
cause  a  more  rapid  gain  in  weight.  Some  cases  kept  upon 
the  breast  showed  improvement  as  far  as  the  nutrition  and 


344  PYLORIC   OBSTRUCTION. 

temperature  were  concerned  by  the  addition  to  the  diet  of  a 
simple  5  per  cent,  solution  of  Dextri-Maltose. 

Why  it  is  so  I  cannot  explain,  but  I  have  noticed  the 
clinical  fact  that  many  cases  which  are  doing  indifferently 
well  upon  the  breast  alone,  gaining  an  ounce  or  two  a  week 
or  just  holding  their  own,  take  a  spurt,  if  given  a  simple 
formula  prepared  as  just  described.  The  bottle  is  given  at 
every  other  feeding,  and  then  gradually  the  baby  is  trans- 
ferred to  artificial  food  entirely.  Whether  this  be  merely 
a  coincidence,  or  whether  it  depends  upon  the  food,  thus 
furnishing  a  clue  as  to  the  ultimate  cause  of  the  spasm,  or 
hypertrophy  which  may  be  causing  the  obstruction,  is  diffi- 
cult to  determine,  but  as  a  practical  therapeutic  fact  it  is 
well  worth  remembering.  I  have  only  seen  this  occur  after 
the  use  of  milk  treated  in  the  following  manner,  viz.,  highly 
diluted,  boiled,  and  modified  either  by  Benger's  Food  or  by 
flour  ball  and  pancreatin. 

Animal  broths  are  at  times  sustaining,  especially  in 
surgical  cases  just  preceding  operation.  They  may  be 
given  by  mouth  or  per  rectum. 

Enemas  of  peptonized  milk  are  useful  for  the  same  pur- 
pose. Too  great  dependence  should  not  be  placed  upon 
them.  Their  bulk  should  always  be  small,  and  not  more 
than  2  should  be  administered  during  each  twenty-four 
hours. 

Mechanical  Measures. — The  one  single  remedy  which 
approaches  specific  proportions  in  the  management  of  non- 
surgical  cases  is  gastric  lavage.  If  nothing  else  be  at  hand, 
plain  warm  water  will  do.  Normal  salt  solution  is  better, 
however,  and  better  still  is  a  solution  of  i  dram  of  bicar- 
bonate of  soda  to  the  pint  of  water.  The  temperature 
should  be  100°  F.  The  washing  should  be  continued  until 


TREATMENT.  345 

the  fluid  comes  away  clear.  The  daily  number  of  washings 
varies  with  the  severity  of  the  vomiting — not  less  than  I 
and  preferably  2  or  3.  If  possible  the  washings  should 
immediately  follow  a  vomiting  spell,  and  immediately  after 
this  food  should  be  administered.  (See  page  363.) 

In  some  instances  the  fluid  enters  readily  enough, 
but  the  contractions  of  the  stomach  are  so  forceful  that  the 
contents  are  shot  out  alongside  of  the  tube.  This  accom- 
plishes as  much  as  if  the  fluid  were  siphoned  away.  There 
is  some  danger,  slight  however,  that  fluid  or  curds  may  be 
aspirated  into  the  larynx  or  bronchi  and  cause  immediate 
suffocation  or,  later,  bronchopneumonia.  In  order  to  avoid 
this  the  catheter  should  be  immediately  withdrawn  during 
the  gush  of  fluid  and  the  infant  inverted.  As  the  case  im- 
proves the  number  of  washings  is  gradually  decreased  and 
finally  omitted. 

It  is  important  to  keep  the  rectal  temperature  between 
99°  and  100°  F.  With  this  in  view  the  baby  should  be 
properly  protected  by  clothing  and  the  judicious  application 
of  external  heat. 

Medicinal. — Drugs  are  only  adjuvants.  I  only  employ 
them  for  a  definite  reason.  Of  the  bromids  I  prefer  the 
strontium  or  the  sodium  salt.  The  former  is  given  in  the 
shape  of  Paraf  Javal's  solution  marketed  by  Chapoteaut. 
Each  fluidram  contains  7^2  grains,  and  from  10  to  15 
minims  are  administered  in  .a  little  water  before  every 
feeding  or  before  alternate  feedings.  From  I  to  2  grains  of 
the  salt  dissolved  in  plain  water  may  be  thus  employed.  I 
have  also  used  sodium  bromid.  It  appears,  however,  to  be 
more  irritating  in  the  stomach  and  more  readily  produces  a 
bromid  rash,  which  in  itself  may  be  an  element  of  danger 
(Complications,  page  334). 


346  PYLORIC   OBSTRUCTION. 

If  the  bromid;  has  no  effect  upon  the  vomiting,  I  have 
made  use  of  an  occasional  dose  of  morphin  sulphate 
ST-  Vsoo  to  gr.  Vsoo  by  hypodermic  injection.  This  has  in 
some  cases  worked  splendidly  and  without  ill-effect.  Where 
the  appetite  has  failed  I  to  2  drops  of  the  tincture  of  nux 
vomica  have  been  of  some  use. 

Impressed  by  the  good  effect  of  liquid  paraffin  in  the 
treatment  of  constipation,  I  believe  that  this  substance 
should  be  given  a  trial  in  the  milder  cases  of  incomplete 
obstruction.  I  have  employed  it  in  but  2  cases  and,  I  be- 
lieve, with  some  good  effect  in  allaying  pyloric  spasm  and 
in  asisting  the  onward  movement  of  the  aliment.  About  ^ 
to  i  dram  should  be  given  three  times  a  day.  Any  of  the 
good  oils,  foreign  or  domestic,  to  be  found  on  the  market 
will  answer  this  purpose. 

Sodium  citrate  is  a  valuable  agent  when  used  in  con- 
junction with  proper  feeding.  Its  purpose  is  to  keep  the 
milk  liquid  in  the  stomach,  so  as  to  assist  in  its  easy  passage 
through  the  pylorus.  To  infants  on  the  breast  I  have  given 
as  much  as  10  or  15  grains  five  or  six  times  a  day,  before 
feeds.  I  believe  however  that  ordinarily  from  2  to  5  grains 
are  sufficient.  I  find  no  ill-effects  from  its  use.  It  should 
enter  into  the  composition  of  every  milk  formula  in  those 
cases  artificially  fed.  The  dose  is  from  I  to  3  grains  for 
every  ounce  of  milk  and  cream  in  the  bottle. 

Codliver  oil,  especially  ia  cold  weather,  should  be  used 
freely  daily  or  bidaily  in  the  form  of  inunctions. 

SURGICAL  TREATMENT  OF  INFANTILE 

PYLORIC  OBSTRUCTION. 

By  John  B.  Deaver,  M.D. 

When  surgical  treatment  has  been  decided  upon  it  be- 
comes necessary  to  select  that  form  of  operation  which  will 


SURGICAL   TREATMENT.  347 

accomplish  the  best  result.  In  doing  this  we  must  be  guided 
not  only  by  the  change  in  the  stomach,  but  also  the  tender 
age  of  the  patient. 

The  operations  that  have  been  done  in  the  attempt  to 
correct  this  condition  are  pylorodosis,  pyloroplasty,  gastro- 
jejunostomy,  and  pylorectomy.  Pylorectomy  has  been  done 
but  once,  so  far  as  I  know,  with  fatal  result.  Gastro- 
pyloroduodenostomy  has  been  done  unsuccessfully  in  i  case. 
Pylorodosis  is  an  operation  which  may  be  quickly  per- 
formed, requires  but  little  exposure  of  the  viscera,  and  is 
theoretically  safe,  but  practically  does  not  give  the  best 
results.  In  a  few  instances  the  pylorus  has  been  split  longi- 
tudinally down  to  but  not  including  the  mucosa  ( Ramstedt) , 
instead  of  stretching,  and  death  has  frequently  resulted 
from  shock  or  from  peritonitis.  In  my  early  experience 
with  this  disease  I  performed  a  number  of  these  operations 
with,  as  a  rule,  unsatisfactory  results;  therefore  I  have  dis- 
carded this  method  entirely.  In  i  of  my  cases  I  had  sub- 
sequently to  make  a  posterior  gastroenterostomy. 

Dufour  and  Fredet  have  collected  36  operations  by  the 
Ramstedt  method,  with  9  deaths.  One  patient  who  re- 
covered required  gastroenterostomy  later.  Personally,  I 
would  strongly  advise  against  this  operation. 

Posterior  gastrojejunostomy  is  the  only  operation  I  now 
perform,  and  the  results  warrant,  I  am  sure,  the  statement 
that  it  is  the  only  operation  to  be  considered.  The  tech- 
nique of  the  operation  is  exactly  the  technique  of  posterior 
gastrojejunostomy  in  the  adult,  the  only  difference  being 
that  it  is  preferable  to  use  smaller  anastomosis  clamps  on 
account  of  the  jejunum  being  so  much  smaller  in  the  child 
than  in  the  adult.  The  essential  points  to  be  considered  in 
this  operation  in  the  child  are,  first,  rapidity;  second,  that 


348  PYLORIC   OBSTRUCTION. 

the  anastomosis,  be  made  as  close  to  the  duodenojejunal 
junction  as  possible,  thereby  preventing  regurgitant  vomit- 
ing ;  third,  that  3  rows  of  sutures  be  used,  the  outermost  of 
linen  and  the  2  innermost  of  chromic  catgut.  The  linen 
suture  should  only  include  the  serous  and  the  muscular 
coats  and  must  be  introduced  with  great  care  on  account 
of  the  thinness  of  the  wall  of  the  jejunum.  Before 
introducing  the  second  row  of  sutures  divide  the  serous  and 
muscular  coats  of  the  stomach  and  small  bowel  between 
one-fourth  and  one-eighth  of  an  inch  from  the  line  of  the 
apposed  viscera.  This  row  of  sutures  is  then  carried 
through  the  divided  coats.  The  third  row  of  sutures  is 
passed  after  the  viscera  are  opened,  and  includes  all  the 
coats. 

AFTER-TREATMENT. 

The  after-treatment  consists  in  keeping  the  child  in  a 
sitting  position  in  bed  by  a  sling  passed  beneath  the  buttocks 
in  the  manner  in  which  all  cases  of  posterior  gastroenteros- 
tomy  are  handled  for  a  few  days  immediately  after  the 
operation.  Nothing  is  given  by  mouth  until  after  the 
passage  of  gas  by  bowel,  which,  in  the  majority  of  in- 
stances, occurs  within  twenty-four  hours.  Then,  if  the 
stomach  be  retentive,  water,  to>  be  followed  by  albumin- 
\vater,  broth,  and  similar  substances  are  allowed.  If  the 
condition  continues  favorable,  diluted  milk  formula,  pre- 
digested  or  not,  may  be  given.  As  the  child  continues  to 
improve  the  milk  formula  is  strengthened  and  a  larger 
quantity  given. 

If  the  stomach  is  not  retentive,  or  if  there  is  vomiting 
irrespective  of  taking  nourishment,  the  stomach  is  to  be 
washed  out.  In  fact,  this  is  the  only  thing  that  accom- 
plishes any  good.  In  my  experience,  to  give  medicines,  as 


AFTER-TREATMENT.  349 

bismuth,  cocaine,  oxalate  of  cerium,  and  such  other  agents 
believed  to  be  of  some  use  in  controlling-  nausea,  is  abso- 
lutely of  no  use  in  cases  of  this  character. 

It  not  infrequently  happens  that  a  few  hours  after 
operation  the  child  will  vomit  some  old  blood  which  emits 
a  disagreeable  odor,  and,  if  so,  lavage  should  be  immediately 
practised. 

It  is  my  practice  to  give  these  children  enteroclysis  for 
two  or  three  days.  At  the  end  of  the  fourth  day  the  bowels 
are  opened  by  enema.  Rarely  it  is  necessary  to  give  an 
aperient  or  purgative.  If  the  condition  is  at  all  favorable 
for  operation  these  cases  should  get  well  with  little  or  no 
anxiety  on  the  part  of  the  surgeon.  Procrastination,  in 
surgical  cases,  in  the  hope  that  the  child  will  be  better  with- 
out operation,  until  the  condition  becomes  alarming,  causes 
operation  to  become  a  matter  of  much  moment,  and  the  con- 
sequent responsibility  of  the  surgeon  to  be  correspondingly 
greater. 

The  incision  is  made  through  the  middle  of  the  right 
rectus  muscle.  In  closing,  the  peritoneum  is  apposed  by  a 
continuous  iodin-catgut  suture.  Two  or  more  interrupted 
silkworm-gut  sutures  are  passed  through  all  tissues,  down 
to  the  peritoneum.  The  sheath  of  the  rectus  is  made  to 
overlap  and  is  fixed  by  a  continuous  iodin  suture.  The  skin 
is  closed  with  silkworm  gut  or  horsehair.  The  interrupted 
stitches  should  not  be  removed  for  nine!  or  ten  days,  the 
child  being  strapped  with  adhesive  plaster.  The  plaster  ex- 
tends completely  around  the  abdomen.  When  the  stitches 
are  removed  too  early,  the  edges  of  the  wound  may  separate, 
causing  ventral  hernia.  I  have  met  this  accident,  but  have 
corrected  it  by  immediate  replacing. 


CHAPTER  XIII. 
SPECIAL  TOPICS. 


DESCRIPTION  OF  APPARATUS. 

SHOULD  his  practice  bring  him  into  frequent  contact 
with  children,  the  physician  should  have  the  apparatus 
pictured  in  Fig.  56  always  at  hand,  in  good  condition  and 
ready  for  use. 

A  consists  of  a  small  glass  funnel  ( i )  holding  not  less 
than  2  ounces  and  preferably  3.  The  funnel  is  attached 
to  a  piece  of  rubber  tubing  (2)  about  6  to  8  inches  in 
length.  To  this  is  connected  a  piece  of  glass  tubing  (3) 
2  to  3  inches  in  length,  and  to  this  is  finally  attached  a  soft, 
red-rubber  catheter  (4),  No.  22  to  No.  26  French.  An 
extra  eyelet  is  cut  into  the  catheter  about  ^2  inch  from 
the  end. 

B  consists  of  a  small,  rubber,  hand-bulb  syringe  (5) 
with  a  hard-rubber  tip  (6).  In  the  figure  it  is  con- 
nected with  a  soft,  red-rubber  catheter,  No.  22  to  No.  26 
French  (7). 

C  is  a  glass  syringe  which  may  be  employed  instead  of 
the  hard-rubber  syringe,  and  is  especially  useful  in  nasal 
feeding. 

D  is  a  rubber  fountain  syringe  holding  2  quarts  (8). 
To  the  hard-rubber  tip  at  the  end  is  attached  a  No.  22  to 
No.  26  soft,  red^-rubber  catheter  (9).  It  may  be  remarked 
that  it  is  not  necessary  for  the  physician  to  possess  more 
than  one  catheter,  as  it  can  be  readily  removed  and  be 
attached  to  that  apparatus  being  employed  at  the  time. 
(350) 


DESCRIPTION    OF   APPARATUS. 


351 


E  is  a  sharp-pointed,  hollow,  steel  needle  (10)  con- 
nected to  a  piece  of  rubber  tubing  (n).  If  the  catheter 
(4)  be  removed  in  A  and  this  rubber  tubing  with  the  needle 
be  connected  to  the  glass  tubing  ( 3 ) ,  a  convenient  apparatus 
for  hypodermoclysis  or  for  intravenous  injection  (by 
gravity)  is  secured. 


• 


Fig.  56. — A,  glass  funnel  (i),  rubber  tubing  (2),  glass  connecting 
tubing  (3),  catheter  No.  22  to  No.  26  French  (4).  B,  small,  rubber, 
hand-bulb  syringe  (5),  small,  hard-rubber  connecting  tip  (6),  catheter 
No.  22  tq  No.  26  French  (7).  C,  glass  syringe.  D,  fountain  syringe 
(8),  catheter  No.  22  to  No.  26  French  (9).  E,  hollow  needle  (10), 
rubber  tubing  (n).  F,  smallest  caliber  catheter. 

F  is  the  very  smallest  red-rubber  catheter  obtainable, 
employed  in  nasal  feeding. 

It  will  thus  be  seen  that  with  this  apparatus  the  phy- 
sician is  equipped  to  perform  such  useful  maneuvers  as 
stomach  washing;  feeding  by  stomach-tube;  nasal  feeding; 
the  administration  of  medicine  via  the  tube,  if  the  patient 
cannot  swallow ;  bowel  irrigation ;  the  giving  of  a  nutrient 


352  SPECIAL  TOPICS. 

or  medicinal  enema  (high  or  low),  and  to  administer  saline 
or  other  medicinal  solutions  by  hypodermoclysis  or  intra- 
venously. 

STOMACH  WASHING  (LAVAGE). 

Solutions  Employed. — Plain  faucet- water  will  do.  Sterile 
water  is  better.  Normal  saline  soluton  is  still  better. 
A  solution  containing  i  dram  of  sodium  chlorid  and 
i  dram  of  bicarbonate  of  soda  to  the  pint  is  best  for 
routine  purposes.  For  special  occasions  tannic  acid  ( i  per 
cent,  to  2  per  cent.),  potassium  permanganate  i :  8000,  silver 
nitrate  i :  10,000,  may  be  of  service  in  the  presence  of 
bleeding,  morphin  or  other  alkaloidal  poisoning,  or  gastric 
ulceration  or  catarrh.  For  the  control  of  the  bleeding  in 
gastric  ulcer  of  adults  Rodman  recommends  filling  the 
stomach  with  hot  water,  the  temperature  being  as  high  as 
is  endurable  by  the  patient.  For  ordinary  purposes  the 
temperature  of  the  solution  should  be  that  of  the  body— 
98°  to  1 00°  F.  The  quantity  employed  depends  upon  the 
indication  for  which  the  washing  is  done.  The  washing  is 
continued  until  the  indication  is  overcome  or  mitigated. 
Ordinarily  from  i  to  2  quarts  are  employed.  As  a  rule, 
but  i  washing  a  day  is  allowed,  although  if  much  benefit 
follow,  as  in  some  cases  of  pyloric  obstruction,  it  may  be 
repeated  two,  three,  and  even  four  times  within  twenty- 
four  hours. 

Technique. — Apparatus  A  is  employed.  The  patient  is 
placed  flat  upon  the  back  and  wrapped  in  a  small  sheet  or 
blanket  in  order  to  secure  the  arms.  The  head  is  steadied 
in  the  median  line  by  an  assistant.  The  catheter  is  made 
moist  with  the  solution  to  be  used.  The  tip  of  the  catheter 
is  passed  along  the  dorsum  of  the  tongue  until  it  touches 


STOMACH   WASHING    (LAVAGE).  353 

the  postpharyngeal  wall.  Pressure  is  continued  and  the 
catheter  will  glide  directly  into  the  esophagus,  through 
which  it  enters  the  stomach.  The  funnel  is  then  held  in  a 
vertical  position  to  allow  gas  to  be  expelled.  This  does  not 
always  occur,  but  some  of  the  gastric  contents  commonly 
appear  at  the  glass  connecting-tubing  or  shoot  into  and 
sometimes  out  of  the  funnel.  The  fluid  is  now  poured  into 
the  funnel  and,  unless  the  infant  struggles,  it  will  gradually 
enter  the  stomach.  As  it  disappears  from  the  funnel  the 
latter  is  again  filled.  Just  as  the  fluid  is  about  to  disappear 
for  the  second  or  the  third  time,  depending  upon  the  age  of 
the  baby,  the  funnel  is  depressed  below  the  level  of  the 
patient  and  the  gastric  contents  are  siphoned  into  a  recep- 
tacle. This  maneuver  is  again  repeated.  This  refilling  and 
siphoning  are  continued  until  the  fluid  returns  clear 
(Figs.  57  and  58). 

If  the  patient  struggles,  and  in  older  children,  the  task 
becomes  less  easy.  The  patient  cries  and  compresses  its 
abdominal  muscles,  and  the  fluid  will  not  enter  the  stomach, 
but  moves  up  and  down  in  the  apparatus.  If  the  indication 
for  the  washing  is  urgent,  the  funnel  must  be  patiently  held 
in  the  vertical  position  until  the  infant  relaxes  or  in  some 
cases  the  operation  must  be  abandoned.  The  straining  may 
be  so  great  as  to  cause  the  tube  to  be  forcibly  expelled 
through  the  mouth.  Under  these  circumstances  the  tube  is 
to  be  replaced  two  or  three  times  before  the  attempt  is 
abandoned.  Straining  may  cause  the  fluid  to  gush  out  of 
the  infant's  mouth.  This  does  not  interfere  with  the  accom- 
plishment of  a  successful  result.  The  stomach  is  cleansed 
whether  the  fluid  is  returned  through  the  apparatus  or  via 
the  infant's  mouth.  In  yet  other  instances  the  catheter 
may  become  blocked  by  tough  mucus  or  curds,  or  both. 

28 


354 


SPECIAL   TOPICS. 


Under  these  circumstances  the  tube  may  be  withdrawn  and 
an  extra  eyelet  may  be  cut  into  its  side,  or  the  apparatus 
may  be  filled  with  the  solution  to1  be  employed  before  pass- 


Fig-  57- — Stomach  washing.    The  funnel  is  held  erect  to  allow 
the  fluid  to  enter  the  stomach. 

ing  the  catheter.  The  tubing  is  pinched  until  the  catheter 
enters  the  stomach.  When  release  of  pressure  is  made  the 
fluid  will  flow  because,  the  apparatus  being  filled,  in  view  of 


STOMACH    WASHING    (LAVAGE). 


355 


the  law  of  the  impenetrability  of  matter  (two  things  cannot 
occupy  the  same  place  at  the  same  time),  no  curd  nor 
mucus  can  enter  the  catheter.  The  entrance  of  the  fluid 


Fig.  58. — Stomach  washing.     The  funnel  is  depressed  to  filter 
away  the  stomach  contents,  which  flow  into  the  bowl. 

itself  into  the  stomach  will  cause  the  curd  or  mucus  to  be 
broken  up,  and  thus  also  the  probability  of  the  one  or  the 
other  blocking  the  apparatus  is  materially  lessened. 


356  SPECIAL   TOPICS. 

Enemata. — Apparatus  B  is  employed.  An  enema  may 
be  either  high  or  low.  A  low  enema  is  given  below  the 
internal  sphincter,  its  purpose  being  to  empty  the  rectum. 
A  high  enema  is  given  above  the  internal  sphincter.  In 
giving  the  low  enema  the  small,  rubber,  hand-bulb  syringe 
is  employed.  In  giving  the  high  enema  this  apparatus  with 
the  catheter  attached  is  used.  The  purpose  of  the  high 
enema  may  be  to  cleanse  the  rectum  and  sigmoid  or  to  place 
medicine  or  nutriment  into  the  lower  bowel.  For  cleansing 
purposes  plain  simple  water  or  saline  solution,  or  a  mixture 
of  soap  and  water  with  the  addition  of  a  small  amount  of 
turpentine  and  glycerin,  may  be  employed.  A  high  enema 
should  always  be  preceded  by  a  low  enema,  thus  avoiding 
blocking  of  the  catheter  by  feces.  The  catheter  is  anointed 
and  passed  within  the  bowel  for  a  distance  of  from  4  to  6 
or  8  inches,  care  being  taken  that  the  catheter  does  not 
curl  upon  itself.  After  being  properly  placed  the  solution 
to  be  employed  is  injected  into  the  bowel  through  the 
catheter  by  means  of  the  small,  rubber,  rectal  syringe,  or  by 
means  of  gravity,  use  being  made  of  a  funnel  or  a  fountain 
syringe. 

A  high  enema  may  also  be  introduced  purely  by  gravity 
without  the  use  of  the  catheter.  The  patient  is  simply 
placed  in  the  knee-chest  position  and  the  tip  of  the  fountain 
syringe  in  apparatus  D  is  anointed  and  gently  inserted  into 
the  rectum.  The  bag  containing  the  fluid  is  held  or  hung 
about  2  or  3  feet  above  the  patient,  and  the  fluid  is  allowed 
to  gently  enter  the  intestinal  canal  by  the  practice  of  inter- 
mittent compression  upon  the  rubber  tube.  Not  more  than 
5  or  6  ounces  of  fluid  should  be  permitted  to  enter  the  bowel 
(Fig.  61).  Within  a  few  minutes  the  patient  will  expel 
the  enema  and  a  large  amount  of  feces. 


COLONIC   IRRIGATION.  357 

COLONIC  IRRIGATION. 

Indications. — When  properly  employed,  colonic  washing 
constitutes  a  useful  therapeutic  asset.     It  is,  however,  not 


Fig.  59. — Colonic  irrigation  with  the  catheter.  The  tip  is  intro- 
duced and  the  buttocks  are  seen  to  be  pressed  together  (so  that  no 
water  can  escape)  in  order  to  balloon  the  rectum. 

without  danger,  especially  when  continued  without  reason 
over  a  long  period  of  time.    A  distinct  indication  must  exist 


358 


SPECIAL   TOPICS. 


and  the  washings  must  cease  as  soon  as  this  is  overcome,  or 
it  appears  clear  that  they  will  accomplish  no  good.     In 


Fig.  60 — Colonic  irrigation  with  catheter.  The  catheter  has  been 
pushed  in  for  its  entire  length  and  the  water  is  seen  escaping  along- 
side of  it  and  over  the  buttocks. 

chronic  constipation  a  single  irrigation  is  useful  to  unload 
a  crowded  bowel.  In  this  condition  it  should  not  be  em- 
ployed more  than  once  within  a  fortnight.  It  is  also  indi- 


COLONIC   IRRIGATION. 


359 


cated  in  eclampsia,  summer  complaint  (intoxication),  intes- 
tinal parasites,   intestinal  putrefaction,   dyspeptic  diarrhea, 


Fig.  61.— Giving  a  colonic  irrigation  or  a  high  enema  without  in- 
serting the  catheter.  The  infant  is  placed  in  the  knee-chest  posture 
and  the  hard-rubber  tip  of  the  syringe  is  simply  placed  within  the  anus 
and  the  water  flows  by  gravity. 

and  in  dysentery.     It  is  one  of  the  most  powerful  means  of 
reducing  high  temperature. 


360  SPECIAL  TOPICS. 

Technique. — Plain  sterile  water,  normal  salt  solution,  or 
medicated  fluids  may  be  employed.  In  intestinal  ulceration 
a  weak  solution  of  silver  nitrate  i :  10,000  or  a  i  or  a  2  per 
cent,  solution  of  tannic  acid  may  prove  beneficial.  The  tem- 
perature of  the  fluid  varies  as  to  the  indications  to  be  met.  In 
all  instances,  except  in  fever,  it  should  be  between  98°  and 
1 00°  F.  If  the  patient  has  fever,  cold  water  or,  better, 
gradually  cooled  water,  or  even  ice-water,  is  valuable. 

Apparatus  D  is  employed.  The  irrigation  is  preceded 
by  a  low  enema.  The  child  is  placed  on  its  left  side  and 
under  its  buttocks  is  arranged  a  suitable  piece  of  rubber  or 
a  small  Kelly  pad,  which  drains  the  fluid  intoi  a  bucket. 
The  catheter  is  oiled.  The  stop-cock  is  released  and  the 
flow  of  fluid  expels  all  air  from  the  catheter.  The  flow  is 
now  shut  off  and  the  tip  of  the  catheter  inserted  just  beyond 
the  internal  sphincter.  The  fluid  is  again  allowed  to  flow 
and  the  buttocks  closely  pressed  together  without  compres- 
sing the  catheter  (Fig.  59).  No  fluid  can  escape  and  the 
lower  bowel  is  ballooned.  After  a  minute  or  two  the 
catheter  is  gently  pushed  in  for  its  entire  length.  As  the 
colon  fills,  the  belly  is  gently  massaged.  The  fluid  escapes 
in  spurts  from  the  anus  along  the  sides  of  the  catheter 
(Fig.  60).  The  irrigation  is  continued  until  the  fluid 
returns  clear. 

The  irrigation  may  be  accomplished  without  the  use  of 
the  catheter,  as  in  giving  a  high  enema,  the  child  being 
placed  in  the  knee-chest  posture  (Fig.  61)  and  the  refilling 
and  the  emptying  of  the  bowel  being  continued  until  it  is 
cleansed.  At  intervals  the  child  may  be  placed  upon  its 
back  with  its  buttocks  elevated  while  the  abdomen  is 
massaged  upward  along  the  left  side  across  and  down  the 
right.  This  insures  the  fluid  reaching  the  ascending  colon. 


NASAL  FEEDING.  361 

Accidents. — In  experienced  hands  nothing  more  than  an 
interference  with  the  easy  flow  of  the  fluid  due  to  the  bend- 
ing of  the  catheter  upon  itself  occurs.  As  the  physician 
pushes  the  instrument  into  the  bowel  the  tip  of  the  catheter 
reappears  again  at  the  anus.  This  may  best  be  avoided  by 
thoroughly  ballooning  the  lower  gut,  or  by  passing  the 
index-finger  into  the  rectum  and  thus  guiding  the  tip  of  the 
catheter  past  any  obstruction.  If  the  catheter  becomes  ob- 
structed from  any  cause,  this  fact  may  be  determined  by 
disconnecting  it  from  the  apparatus  temporarily,  when  no 
fluid  will  flow  through  it  from  the  bowel.  There  is  some 
slight  danger  of  rupturing  an  ulcerated  bowel  if  the  rubber 
bag  be  elevated  too  high  above  the  child. 

NASAL  FEEDING. 

Indications. — Unconsciousness.  If  the  child  for  any 
other  reason  cannot  swallow,  as  in  inflammatory  and  infec- 
tious conditions  of  the  mouth  and  throat  and  after  certain 
operative  measures  upon  these  parts,  and  in  cases  of  tetanus. 

Technique. — The  infant's  hands  and  arms  are  secured 
by  a  towel  wrapped  around  its  body.  The  head  is  steadied 
in  the  median  line.  Apparati  F  and  C  are  employed.  The 
calibre  of  the  catheter  must  be  the  smallest  obtainable.  The 
catheter  is  anointed  with  oil.  It  is  passed  toward  the 
posterior  nares,  along  the  floor  of  the  nose.  The  index- 
finger  of  the  free  hand  is  passed  into  the  fauces  to  guide  the 
tip  into  the  esophagus,  otherwise,  striking  the  prominence 
of  a  cervical  vertebra,  it  may  become  impinged  here  and 
the  bulk  of  the  tube  accumulate  in  the  throat,  or  the  tip  may 
come  out  of  the  mouth.  After  the  tip  has  entered  the  stom- 
ach, as  is  evidenced  by  the  appearance  of  gastric  contents 
at  the  outlet  of  the  tube  projecting  from  the  nose,  the  food, 


362 


SPECIAL  TOPICS. 


previously  warmed,  may  be  slowly  injected  by  means  of  the 
glass  syringe- (C).     Instead  of  using  the  syringe  the  food 


Fig.   62. — Nasal   feeding. 

may  be  permitted  to  slowly  gravitate  by  connecting  a  small 
glass  funnel  (A,  i)  with  the  projecting  end  of  the  catheter 
and  into  this  the  food  is  emptied. 


FEEDING  BY  STOMACH-TUBE  (GAVAGE).  363 

\Yhere  necessary  the  stomach  may  be  washed  out 
through  the  nose  before  the  food  is  allowed  to  enter,  and 
medicine  may  also  be  administered  in  this  fashion.  The 
maneuver  of  nasal  feeding  is  usually  easily  accomplished, 
and  without  inconvenience  to  the  infant. 

FEEDING  BY  STOMACH-TUBE  (GAVAGE). 

Indications. — When  the  patient  will  not  or  can  not 
swallow.  This  may  be  due  to  inflammatory  conditions  of 
the  throat  or  mouth,  to  paralytic  phenomena,  as  after 
diphtheria  or  in  cases  of  ascending  paralysis,  or  in  tetanus. 
Inability  to  swallow  is  a  part  of  the  clinical  picture  of  coma, 
as  seen  in  convulsions,  meningitis,  infantile  paralysis,  after 
head  trauma,  and  during  nephritis.  Gavage  is  a  valuable 
adjunct  in  some  cases  of  forced  feeding  or  in  anorexia,  or  in 
cases  of  persistent  vomiting  associated  with  acute  intestinal 
intoxication.  Food  given  in  this  manner  is  often  retained 
when  it  would  be  vomited  if  taken  in  the  ordinary  way. 
To  the  careful  clinical  observer  gavage  will  suggest  itself  in 
many  other  conditions,  not  necessary  to  be  enumerated.  It 
should  be  discontinued  the  moment  the  necessity  for  it  ceases 
to  exist. 

Technique. —  The  same  apparatus  (A)  is  employed  as 
in  stomach  washing,  and  the  same  method  of  introducing 
the  tube  is  followed.  The  food,  adapted  to  the  needs  of  the 
individual  case,  but  always  liquid  and  previously  warmed, 
is  allowed  to  slowly  enter  the  stomach  by  the  attendant 
making  regular  but  intermittent  compression  upon  the  tube. 
On  the  other  hand,  one  may  dispense  with  the  funnel  and 
the  aliment  may  be  slowly  injected  through  the  catheter 
by  means  of  a  glass  or  other  syringe,  as  in  nasal  feeding. 
During  withdrawal  the  tube  must  be  compressed  and  re- 


364  SPECIAL  TOPICS. 

moved  with  one  swift  stroke,  between  gags.  Otherwise 
the  gastric  contents  may  be  shot  out  around,  with  and  after 
the  tube. 

FEEDING  BY  BOWEL. 

Nutrient  Enemata. — The  purpose  of  this  method  of 
feeding  is  to  sustain  life  over  critical  periods  of  acute  food 
intolerance  or  anorexia,  and  to  reinforce  mouth  feeding 
when  the  stomach  is  non-retentive.  It  may  also  be  employed 
during  coma  from  any  cause.  While  it  should  be  tried  as 
a  dernier  ressort,  in  my  opinion  it  rarely  renders  signal 
service  in  saving  life.  It  may  also  be  employed  after  opera- 
tions upon  the  stomach  or  upon  the  other  organs  of  the 
upper  abdomen.  It  cannot  be  depended  upon  as  the  sole 
source  of  introducing  nourishment  for  any  great  period  of 
time. 

Technique. — The  lower  bowel  should  previously  be 
emptied  by  a  suppository  or  preferably  by  a  cleansing  high 
enema  of  simple  saline  solution.  After  this  the  patient 
should  rest  at  least  one-half  hour  in  order  to  permit  any 
rectal  irritation  to  pass  away.  Apparatus  B  is  employed. 
The  rubber  catheter  is  well  anointed  with  oil  and  introduced 
into  the  bowel,  for  a  distance  of  from  4  or  5  inches.  This 
is  accomplished  with  a  variable  degree  of  ease  in  different 
individuals.  The  infant  is  placed  on  its  left  side  and  the 
buttocks  are  slightly  elevated.  The  enema  heated  to  100° 
F.  is  slowly  injected  by  means  of  the  soft-rubber,  hand-bulb 
syringe  or  by  means  of  a  glass  syringe,  or  it  is  allowed  to 
flow  in  by  gravity,  by  connecting  apparatus  A  at  the  glass 
tubing  (3)  to  the  free  end  of  the  catheter.  From  ten  to 
fifteen  minutes  should  be  consumed  in  getting  the  fluid  into 
the  bowel,  whatever  method  be  employed.  When  all  has 


FEEDING  DURING  INFECTIOUS  DISEASES.  365 

entered,  the  catheter  is  pinched  and  swiftly  withdrawn. 
The  infant  is  permitted  to  lie  on  its  left  side  with  its  but- 
tocks elevated,  or  it  is  placed  for  a  few  moments  in  the 
knee-chest  posture  while  the  colon  is  massaged  upward  on 
the  left  side,  across,  and  down  the  right.  The  bulk  of  the 
enema  should  never  exceed  4  to  5  ounces  in  a  child  and  in 
an  infant  never  more  than  I  to  2  ounces.  Not  more  than  2 
nutrient  enemata  should  be  given  within  twenty-four  hours, 
and  they  should  be  at  least  twelve  hours  apart.  Any 
attempt  to  increase  the  bulk  or  the  frequency  of  administra- 
tion will  defeat  the  purpose  for  which  they  are  given,  for 
the  rectum  speedily  becomes  irritable  and  expulsion  occurs. 
Composition. —  Various  formulae  have  been  given.  All 
are  perhaps  good.  None  appear  to  me  to  possess  any 
special  advantage.  The  following  is  offered  as  being  suit- 
able in  most  instances: — 

One  egg 

4  oz.  of  completely  pancreatized  milk  (at  least  30  minutes). 

I  oz.  of  water. 

Deodorized  tincture  of  opium,  i  to  5  drops. 

Ex.  of  pancreatin,  10  grains. 

Sodium  bicarbonate,  10  grains. 

This  may  be  given  in  whole  or  in  part.  If  desired,  from 
i o  to  60  minims  of  whisky  may  be  added. 

FEEDING  DURING  THE  ACUTE  INFECTIOUS 
DISEASES. 

The  burden  of  an  infectious  process  is  shared  by  all 
the  vital  organs.  From  this  depression  of  function  the 
alimentary  canal  does  not  escape.  Hence  the  tolerance  for 
food,  i.e.,  the  power  for  digestion  and  for  assimilation,  is 
variously  diminished,  depending  upon  the  resistance  of  the 
individual  and  upon  the  severity,  character,  and  duration 


366  SPECIAL  TOPICS. 

of  the  infectious  disease.  This  diminished  digestive  power 
is  commonly  seen  when,  during  the  course  of  an  acute  in- 
fection, the  bowel  movements,  which  previously  were  nor- 
mal, now  show  the  evidences  of  dyspepsia,  curds,  mucus, 
greenish  discoloration.  So  much  so  is  this  the  case  that 
not  infrequently  the  mistake  is  made  of  overlooking  the  in- 
fection, which  may  be  more  or  less  obscure,  and  o<f  regard- 
ing the  case  as  purely  one  of  food  intolerance  or  of  alimen- 
tary disturbance.  I  have  seen  this  error  made  repeatedly, 
for  instance,  with  reference  to  acute  otitis  media.  An 
infant  falls  ill  with  fever  and  the  bowels  become  disturbed. 
The  patient  is  treated  with  reference  to  these  until  a  dis- 
charge appears  at  the  ear,  or  a  specialist  having  been  called, 
or  the  doctor  himself  becoming  suspicious  from;,  for  in- 
stance, the  high  leucocyte  count,  or  from  a  general  knowl- 
edge that  inflamed  ears  often  occur  in  infants  without  pain 
and  with  fever  as  their  sole  symptom,  the  error  is  dis- 
covered before  rupture  occurs  as  the  result  of  a  careful  ear 
examination.  In  one  instance  this  error  almost  led  to  a 
fatal  issue,  as  an  intense  mastoid  infection,  requiring  opera- 
tion, occurred.  The  child  had  been  ill  a  week  before  the 
ear  infection  was  detected. 

The  character  of  the  infection,  i.e.,  the  nature  of  the 
toxin,  has  a  very  important  determinating  influence  upon 
the  degree  of  severity  of  the  food  intolerance.  Thus  the 
toxin  of  pneumonia  seems  very  potent  in  this  respect,  while, 
on  the  other  hand,  those  of  the  acute  exanthemata,  scarlet 
fever,  measles  and  varicella,  and  of  diphtheria  seem,  to 
exert  scarcely  any  serious  effect  upon  the  digestion.  In- 
fluenza, on  the  other  hand,  is  very  depressing.  With  the 
exception  perhaps  of  scarlet  fever,  a  speedy  return  may  be 
made  to  the  normal  amounts  of  the  food  to  which  the  in- 


FEEDING  DURING  INFECTIOUS  DISEASES.  367 

dividual  has  been  accustomed  during-  health.  Even  in  this 
exception  we  must  be  cautious,  not  because  of  the  reduction 
in  food  tolerance  per  se,  but  because  the  scarlatinal  toxin  is 
especially  irritating  to  the  renal  tissue.  Nephritis  commonly 
results,  and  it  is  with  a  view  of  preventing  this  complication 
that  special  measures  must  be  pursued. 

The  damaging  effects  of  the  pneumotoxin  upon  food 
tolerance  and  the  best  means  of  overcoming  it  are  of  suffi- 
cient importance  to  require  detailed  comment.  The  pneu- 
motoxin probably  acts  in  two  ways.  First,  simply  as  most 
toxins  act — by  diminishing  the  functional  activity  of  the 
glands  of  digestion  and  the  assimilative  apparatus,  and, 
second,  by  directly  paralyzing,  in  susceptible  individuals, 
the  unstriped  muscle-fibre  of  the  intestines,  because  tym- 
panites is  a  common  complication  of  this  disease.  It  should 
also  be  emphasized  that  it  is  a  highly  dangerous  one,  and 
one  of  the  most  fatal.  From  the  outset,  therefore,  it  must 
be  borne  in  mind,  and  every  means  should  be  employed  to 
prevent  its  incidence  or  to  mitigate  its  severity,  or  to  re- 
move it  entirely.  The  last  ofttimes  is  a  baffling  and 
impossible  task. 

The  author  recommends  that  in  nurslings  mother's  milk 
should  if  possible  be  the  sole  source  of  nutriment.  If  the 
infant  be  bottle-fed,  milk  in  all  forms  should  be  excluded, 
if  possible,  as  well  as  sugars  and  starches.  If  it  be  impos- 
sible to  omit  milk  entirely,  it  should  be  given  skimmed  and 
highly  diluted  and  pancreatized,  or  modified  by  the  addi- 
tion of  flour  ball  and  pancreatin,  or  of  Benger's  Food. 
Reliance  should  be  placed  mainly  upon  animal  juices  and 
broths  and  upon  protein  foods.  The  last,  in  sucklings, 
should  consist  of  egg-albumin  water,  in  addition  to  the 
animal  juices.  In  older  children  skinned  mashed  peas  and 


368  SPECIAL  TOPICS. 

Lima  beans  and  eggs  boiled  or  coddled  two  minutes  should 
be  employed.  Breadcrumbs  made  of  dry  stale  bread  may 
be  rubbed  up  with  the  egg.  In  addition  to  the  milk  prepara- 
tions above  indicated,  Finkelstein's  eiweissmilch  or  plain 
buttermilk,  or  one-third  milk  and  two-thirds  water,  boiled 
with  Larosan,  may  be  employed.  Should  constipation 
occur  as  the  result  of  this  feeding,  rectal  enemata,  sup- 
positories, or  tonic  laxatives,  as  the  aromatic  fluidextract  of 
cascara  sagrada  in  ^2 -dram  doses,  should  be  used.  Dras- 
tic purgatives,  as  calomel  and  castor  oil,  often  cause  the 
tympanites  to  become  worse  by  further  relaxing  the  intes- 
tinal rmiscularis.  The  lack  of  sugar  may  be  met  by  the  use 
of  saccharin.  Water  in  abundance  should  be  given  to 
attenuate  the  pneumotoxin. 

Aside  from  the  dietary  measures  advocated,  the  good 
effect  of  the  milk  of  asafetida  in  a  dose  of  ^  or  I  dram 
by  mouth,  or  of  2  ounces  by  enema  alone,  or  combined  with 
10  grains  of  charcoal,  should  not  be  forgotten.  While 
serving  as  interne  oil  my  service  at  the  Mt.  Sinai  Hospital, 
Dr.  M.  I.  Moss  devised  the  following  medicinal  enema, 
which  was  frequently  employed  with  excellent  effect : — 

One-half  ounce  of  an  emulsion  made  with  acacia  con- 
tains 5  minims  of  the  spirits  of  turpentine,  2  fluidrams  of 
the  emulsion  of  asafetida,  and  i  dram  each  of  powdered 
charcoal  and  bismuth  subcarbonate. 

The  application  of  cold  compresses,  of  hot  turpentine 
stupes,  or  of  the  warmed  spice  poultice  (a  small  oblong  bag 
is  made  of  muslin  and  partly  filled  with  allspice  and  securely 
sewed  on  all  four  sides)  to  the  abdomen,  may  often 
assist  in  reducing  the  tympanites.  I  have  seen  very  little 
effect  from  the  hypodermic  injection  of  eserin  salicylate  or 
of  atropin  sulphate.  Digestants,  as  the  extract  of  pan- 


FEEDING   DURING   INTUBATION.  369 

creatin  and  of  taka-diastase,  2  gr.  each,  administered  four 
times  daily,  may  be  of  some  assistance.  The  permanent 
insertion  of  a  No.  22  to  No.  26  French  soft-rubber  catheter 
high  into  the  bowel  may  facilitate  the  passage  of  the  gas. 

FEEDING  IN  NEPHRITIS. 

After  following  many  cases  of  acute  and  subacute 
nephritis  to  recovery  I  am  convinced  that  the  investigations 
of  Martin  H.  Fischer  with  reference  to  sodium  chlorid  are 
not  only  correct,  but  that  they  provide  invaluable  data  in 
the  treatment  of  this  disease.  I  therefore  advocate  the 
addition  of  salt  to  the  diet  of  all  nephritics  in  plentiful 
quantities,  and  administer  it  as  well  per  rectum,  hypoder- 
mically  and  intravenously.  Aside  from  this  there  is  no 
need  for  further  comment  except  to  advise  the  administra- 
tion of  wholesome,  well-cooked,  and  easily  digested  foods 
in  small  quantities. 

FEEDING  DURING  INTUBATION. 

The  blandest  of  food  should  be  given  in  order  not  to 
induce  coughing,  as  this  may  cause  the  tube  to  be  expelled. 
Milk  and  milk  foods  are  best.  Infants  at  the  breast  very 
often  can  continue  this  method  of  feeding,  provided  the 
milk  be  pumped  and  fed  with  a  spoon  or  dropper.  If  swal- 
lowing cannot  be  accomplished  the  food  may  be  given 
through  a  stomach-tube  or,  better  yet,  by  nasal  feeding.  The 
question  of  feeding  during  intubation  is  largely  a  problem  of 
position.  Some  patients  have  trouble  when  attempting  to 
swallow  liquids.  This  may  be  overcome  by  holding  the 
baby  so  that  its  head  is  lower  than  its  trunk.  This  is 
known  as  the  Casselberry  position. 


370  SPECIAL  TOPICS. 

HYPODERMOCLYSIS. 

This  means  the  injection  of  fluids,  usually  normal 
saline  solution,  under  the  skin  for  the  purpose  of  ab- 
sorption. 

Indications. — It  is  useful  in  all  conditions  associated 
with  a  great  loss  of  the  body  fluid  and  in  acute  or  chronic 
toxic  states.  Thus  it  finds  its  chief  indication  in  cholera 
infantum  (intoxication),  hemorrhage,  certain  types  of 
infantile  atrophy,  chronic  diarrhea,  acute  infectious  diseases 
associated  with  suppression  of  the  urine,  asphyxia,  acute 
and  chronic  nephritis,  uremia,  certain  anemias,  and  some- 
times after  operation. 

Physiologic  Action.— The  effect  produced  depends 
largely  upon  the  extra  amount  of  water  which  enters  the 
system  and,  according  to  the  researches  of  Martin  H. 
Fischer,  the  sodium  chlorid  has  a  direct  specific  action  in 
controlling  the  solution  of  the  colloidal  substances  of  which 
the  kidney  is  composed.  This  is  a  direct  contradiction  to  the 
commonly  accepted  opinion  that  common  salt  is  largely  con- 
traindicated  in  the  nephritides.  The  imbibed  water  in- 
creases the  normal  fluids;  of  the  body  and  bathes  the  dried 
and  parched  tissues.  The  volume  of  the  blood  is  increased 
and  the  arterial  pressure  augmented.  The  force  and  the 
volume  of  the  cardiac  beat  is  strengthened.  The  water 
dilutes  the  toxins  and  minimizes  their  deleterious  action 
upon  the  internal  viscera.  The  chlorid  of  sodium  inhibits 
the  action  of  acids  in  causing  the  solution  of  the  normal 
tissue  colloids.  The  increased  diuresis  causes  the  more 
rapid  elimination  of  these  toxins. 

Technique. — Apparatus  A  is  employed  except  that  the 
catheter  (4)  is  replaced  by  connecting  apparatus  E  to  the 
glass  tubing  (3)  of  A.  The  skin  of  the  abdomen  is 


HYPODERMOCLYSIS. 


371 


the  preferable  site  for  injection.  A  point  is  sterilized  by 
the  application  of  a  little  tincture  of  iodine.  The  apparatus 
is  filled  with  the  saline  solution  and  all  air-bubbles  are 


Fig.  63. — Hypodermoclysis. 

eliminated.  The  needle  is  introduced  well  under  the  skin 
into  the  subcutaneous  cellular  tissue.  The  compression  upon 
the  rubber  tubing  is  released.  The  funnel  is  elevated  and 


372  SPECIAL  TOPICS. 

the  fluid'  is  permitted  to  flow  gently  by  gravity.  A  tumor 
immediately  appears  and  increases  in  size  according  to  the 
amount  of  fluid  injected  (Fig.  63).  The  tumor  is  gently 
massaged  in  order  to  facilitate  the  distribution  of  the  solu- 
tion under  the  skin.  Should  the  flow  appear  to  be  in- 
hibited the  needle  may  be  pushed  in  to  its  full  length  and 
pointed  in  different  directions  from  time  to  time.  When 
sufficient  fluid  has  entered  (from  2  to  6  ounces)  the  needle 
is  withdrawn  and  the  puncture  sealed  with  collodion  and 


Fig.  64. — Necrosis  and  ulceration  from  the  subcutaneous  injection 
of  carbonate  of  soda  and  sodium  chlorid  solution.  Slough  due  to 
the  alkali. 

a  bandage  applied.  Within  a  brief  space  of  time,  from  one- 
half  to  one  hour,  the  fluid  will  have  been  absorbed  and  the 
swelling  will  have  disappeared.  The  injection  of  the  fluid 
is  accompanied  by  very  little  pain.  The  temperature  of  the 
solution  in  the  funnel  should  be  maintained  at  about  120°  F. 
As  the  fluid  leaves  the  needle-point  the  temperature  will  be 
about  normal.  Too  large  a  quantity  of  fluid  is  not  to  be 
injected  at  one  site,  nor  should  the  same  site  be  selected  too 
often.  Only  in  this  way  may  gangrene  of  the  skin  and 
ulceration  be  prevented,  especially  in  delicate  infants. 
Should  a  white  area  appear  upon  the  swelling  the  injection 


HYPODERMOCLYSIS.       .  373 

should  immediately  cease,  as  this  means  that  the  circulation 
of  that  particular  spot  has  been  cut  off  and  gangrene  of  the 
skin  may  result.  This  phenomenon  occurs  not  infrequently 
as  the  result  of  placing  the  needle  between  the  layers  of  the 
skin  instead  of  under  the  skin,  or,  as  above  indicated,  from 
permitting  too  much  fluid  to  enter.  Alkalies,  such  as  the 
bicarbonate  of  soda  or  the  carbonate  of  soda,  should  never 
be  employed  in  the  solution,  as  they  invariably  produce 
gangrene  and  ulceration  (Fig.  64).  Abscesses  are  a  rare 
occurrence. 


INDEX. 


Acacia-water,  149 
Adaptation    of    cows'    milk    (see 
also  Cows'  milk,  and  Artifi- 
cial feeding), 
alkalies  in,  90 
home  method  of,  76,  95 
hygiene  of,  96 
indications  of  success  in,  77, 

100 

methods  of,  74 
prescription  forms,  for  use  in, 

75,  85 

sodium  bicarbonate  in,  91 
sodium  citrate  in,  91 
theory  of,  68 
Agar-agar,  256 

Albumin-milk  (see  Eiweissmilch). 
Albumin-water,  121 
Apparatus    for    general    pediatric 

work,  350 

Artificial  feeding,  49 
caloric  method  of,  51 
cereal  decoctions  in,  51 
deficiency    of    food    elements 

in,  114 
digestive  disturbances  in,  194- 

114 

formulas  for  use  in,  77-81 
improper    quantities    of    food 

elements  in,  115 
in  cases  of  delicate  and  sick 

infants,  116 

in  infantile  atrophy,  170 
methods  of,  49 
necessity   of   individualization 

in,  52!  103 

quantities     and     intervals    of, 
101 


Artificial  feeding,  table,  102 
while  travelling,  104 

Babcock's  test,  21 
Barley-water  in  digestive  disturb- 
ance of  breast-fed,  34 
in  fat  disturbance,  112 
in  protein  intolerance,  107 
preparation,  87 
Beef-broths,  145;  jelly,  146;  teas, 

144 
Benger's    food,    composition    and 

use  of,  135 
in  diarrhea,  271 
in  infantile  atrophy,  178 
in  infectious  diseases,  367 
in  protein  intolerance,  109 
in  pyloric  obstruction,  341,  343 
Bottles     (see    Adaptation,    home 

method). 

Breast  (see  also  Mammary  gland), 
abscess,  9 
caked,  8 
Breast-feeding    (see   also   Human 

milk). 

advantages  of,  26 
contraindications  to,  41 
digestive  disturbances  in,  27 
during  illness,  44 
hygiene  of  mother,  42 
indications  for,  2 
metabolic    and    digestive   dis- 
turbances in,  32 
method  of,  38 

physician's  responsibility  in,  1 
successful,  29 

system  and  regularity  in.  28 
table  for,  40 

(375) 


376 


INDEX. 


Breast-feeding,  unsuccessful,  29 

vomiting  in,  33 
Bronchial    asthma    in    exudative 

diathesis,  305 
Broths,  145,  146 
Bulgarian  bacilli,  121 
Buttermilk  (Blockley)  in  diarrhea, 
269 

conserve,  125 

in  curd  division,  71 

indications  for,  124 

in  fat  intolerance,  112 

in  infantile  atrophy,  175 

in  protein  intolerance,  110 

in  sugar  intolerance,  73,  114 

in  vomiting,  238 

prepared,  123 

substituted  for  milk  formula,  71 

Calcium  casein,  55 

Calomel  in  diarrhea,  267,  268 

Caloric  feeding,  82 

Cane-sugar,  136 

Carbohydrates  (see  Sugar,  etc.). 

Cascara    sagrada    in   constipation, 

257 
Castor  oil  in  diarrhea,  267,  268 

in    digestive    disturbances    of 
breast-fed,  34 

in  fat  intolerance,  112 

in  protein  intolerance,  107 

in  sugar  intolerance,  114 
Celery,  stewed,  148 
Cereal-gruels,  in  infantile  atrophy, 
174 

in  milk  adaptation,  71 

in  rickets,  214 

in  vomiting,  241 

preparation  of,  86 
Chvostek's  sign,  282 
Codliver  oil  in  rickets,  218 

in  spasmophilia,  294 
Colostrum,  13,  14 
Condensed  milk  in  rickets,  187 

composition  of,  131 


Constipation,  247 
causes  of,  247 

correction  of  formulas  in,  249 
fat  in,  250 
fruit- juices  in,  251 
in  the  breast-fed,  248 
in  complete  pyloric  obstruction, 

318 

in    incomplete    pyloric    obstruc- 
tion, 325 

in  older  children,  252 
in  rickets,  194 
massage  balls  in,  258 
medicinal  treatment,  254 
spondylotherapy  in,  259 
sugar  in,  250 

Convulsions  in  spasmophilia,  294 
Cornmeal  gruel,  147 
Cornstarch,  147 
Cows,  breeds  of,  54 
care  of,  62 

use  of  chloroform  in,  294 
Cows'    milk    (see    also    Artificial 

feeding,  and  Adaptation), 
adulteration    and    contamina- 
tion, 58 
analysis  of,  60 
antibodies  in,  73 
bacteria  in,  57 
collection  and  care  of,  63 
compared    with   human    milk, 

67 

fat  in,  54,  72 
grades  of,  65 
idiosyncracy  to,  118 
microscopic  appearance  of,  57 
modification  of   (see  Adapta- 
tion). 

protein  in,  55,  70 
salts  in,  57 
sugar  in,  56,  72 
watering     and     preservatives, 

detection  of,  60 
Cream,  55 
Curd  modifiers,  133 


INDEX. 


377 


Decomposition  (see  Infantile  atro- 
phy). 
Dermal  phenomenon  in  exudative 

diathesis,  301 

Dextri-Maltose,  composition,  136 
in  infantile  atrophy,  180 
in  pyloric  obstruction,  343 
in  sugar  intolerance,  114 
Dextrinized  gruels  as  diluents,  86 
in  protein  intolerance,  108 
preparation  of,  89 
Diarrhea,  260 
causes,  260 
in  bottle-fed,  269 
in  breast-fed,  264 
in  children  with  teeth,  274 
postoperative,    in   pyloric   ob- 
struction, -340 
symptoms  of,  262 
treatment  of,  265,  266-268,  269 
Diet  at  12  months,  138 

table,  140 
at  18  months,  140 

table,  141 
after  second  year,  141 

table,  142 
Diluents,  85 
Dyspepsia,  107,  264 

Eczema   (see  also  Exudative  dia- 
thesis). 

of    the    cornea    (Czerny), — see 
Phlyctenular    conjunctivitis. 

of  the  face  and  head,  303 

seborrhoische     universale,     302, 
303 

vacciniformis,  304 

vesiculosum,  304 
Eggs,  148 
Eiweissmilch,  126 

in  acute  infections,  368 

in  curd  division,  71 

in  diarrhea,  269 

in  infantile  atrophy,  177 

in  protein  intolerance,  110 


Eiweissmilch     in     sugar     intoler- 
ance, 73,  114 
in  vomiting,  238 
preparation  of,  126 
Electrical  phenomenon  in  spasmo- 

philia,  284 
Enemata,  356 
in  pyloric  obstruction,  344 
in  vomiting,  341 
medicinal,  368 
nutrient,  364 
Exudative  diathesis,  297 
(See  also  Eczema.) 
association     of     spasmophilia 

with,  298 
diagnosis  of,  307 
etiology  of,  297 
respiratory  symptoms  in,  305 
skin  lesions  in,  301,  309 
symptoms,  general,  300 
treatment  of,  308 

Facial    phenomenon    in    spasmo- 
philia, 282 
Farina,  147 

Fat,  deficiency  of  in  rickets,  187 
digestion  of,  72 
indigestion  in  breast-fed,  33 
Fat  intolerance,  110 
in  rickets,  215 
treatment  of,  112 
urine  in,  112 
vomiting  in,  111,  236 
Feeding  (see  also  Artificial  feed- 
ing,    and     Breast     feeding. 
The    various    problems    of 
feeding  are  considered  un- 
der their  respective  titles), 
by   bowel    (see    Enemata,    Nu- 
trient). 

by  nose   (see  Nasal  feeding), 
by  stomach-tube   (see  Gavage). 
during  intubation,  369 
in  acute  infectious  diseases,  365 


378 


INDEX. 


Feeding  in  nephritis,  369 
stomach  capacity,  234 
Flour  ball,  71 

dextrinized  or  browned,  134 
in  infectious  diseases,  367 
in  protein  intolerance,  108 
in  pyloric  obstruction,  343 
preparation  of,  133 
Food    maximum    (von    Pirquet), 

105 

minimum  (von  Pirquet),  105 
Formulas  (see  Adaptation), 
determination      of      percentage 

strength,  81 

Fullers'  earth  in  diarrhea,  271 
in  exudative  diathesis,  309 

Galactogogues,  37 
Gavage,  363 
Gelatin,  149 
Goats'  milk,  52 

Holland  rusk,  149 
Holt  cream  gauge,  21 

milk-secretion  estimate,  21 
Human  milk,  analysis  of,  18,  25 
bacteriology  of,  17 
chemistry  and  physics  of,  14 
composition  of,  17 
failure  of  secretion  of,  30 
fat  in,  16,  21 
microscopic     appearance     of, 

14,25 

modification  of,  35-37 
proteins  in,  17 
quantity  of,  20 
salts  in,  17 
significance  of   leucocytes  in, 

25 

sugar  in,  17 

Hypodermoclysis  in  diarrhea,  272 
indications  for,  370 
in  infantile  atrophy,  182 
in  vomiting,  241 
technique,  370 


Imperial  granum,  136 
Indigestion    (see  Fat,   Sugar  and 

Protein   intolerance,    and   In- 
digestions). 
Infantile  atrophy,  150 

author's    theory    of    etiology, 
153 

complications  in,  162 

diagnosis  of,  164 

etiology  and  pathology  of,  150 

starch  injury  in,  160 

symptoms  of,  156 

treatment  of,  169-182 

weight  curve  in,  161 
Intestinal    fermentation    and    de- 
composition, 260,  261 
Intoxication,  113,  264 

Junket,  148 

Lactic  acid  milk,  121 
Lactic  acid  tablets  (see  Bulgarian 
bacilli). 

in  infantile  atrophy,  113 
Lactose,  digestion  of,  73 

estimation  of,  24 

in  summer  diarrhea,  72 

(See      Substitutes      for      malt 
sugar.) 

tablets,  121 
Larosan,  128 

in  acute  infections,  368 

in  diarrhea,  270 

in  exudative  diathesis,  309 

in  infantile  atrophy,  177 
Lavage  in  pyloric  obstruction,  344 

in  vomiting,  241 

solutions  for,  352 

technique,  352 
Leiner's  disease,  303 
Lime-salts,  deficiency  of,  in  rick- 
ets, 188 

Lime-water,  148 
Loeflund's  food  maltose,  136 
Lutein,  37 


INDEX. 


379 


Magnesia,  milk  of,  in  constipation, 

256 

Maltine   in   infantile   atrophy,   174 
Maltose,  digestion  of,  73 
Maltropon,  37,  44 
Malt  soup,  71 

in  infantile  atrophy,  90 
in  protein  intolerance,  110 
Loeflund's,  89 
sugar,  substitutes  for,  136 
Mammary  gland  (see  also  Breast), 
anatomy  and  histology  of,  3 
hygiene  of,  6 

Marasmus  (see  Infantile  atrophy). 
Mead-Johnson's      Dextri-Maltose, 

136 

Mehlnahrschaden,  152,  160,  163 
Milk    (see    Human    milk,    Cows' 

milk,  Goats'  milk), 
boiled,  in  infantile  atrophy,  173 
Mineral  oil,  254 
Murphy  treatment,  241 

Nasal  feeding,  361 

Nipples      (see     also     Adaptation, 

home). 

artificial,  in  breast  feeding,  6 
depressed,  8 

excoriations  and  fissures  of,  6,  7 
treatment  during  puerperium,  6, 

8 

Nutrose    in    exudative    diathesis, 
309 

Oatmeal-water,  88 
Olive  oil  in  constipation,  255 
Onions,  stewed,  148 
Orange-juice,  149 

Pancreatization   in   infantile  atro- 
phy, 175 

Pancreatized   milk   in   protein   in- 
tolerance, 108 
in  fat  intolerance,  113 

Paraf  Javal's  preparation,  184,  241 


Paraf  Javal's   preparation   in   in- 
fantile atrophy,  184 
in  pyloric  obstruction,  345 
in  nervous  vomiting,  240 
Pasteurized  milk,  91 
Pepper  &  Meigs,  method  of  milk 

adaptation,  49 
Percentage  feeding,  74 

method  of  milk  adaptation,  SO 
Peroneus  phenomenon  in  spasmo- 

philia,  284 

Phlyctenular  conjunctivitis,  304 
Phosphorus  in  rickets,  218 

in  spasmophilia,  294 
Potato,  baked,  147 
Pott's  disease,  similarity  to  rickets, 

200 
Protein  intolerance,  106 

in  exudative  diathesis   (Fink- 

elstein),  300 
in  infantile  atrophy,  172 
in  rickets,  214 
resume  of  treatment,  110 
stools  in,  106,  107 
treatment  of,  107 
vomiting  in,  238 
Proteins,  deficiency  of,  in  rickets, 

187 

determination  of,  in  milk,  22 
digestion  of,  70 
Esbach's  tube  in  determination 

of,  24 
formula    for   determination   of, 

24 

indigestion  of,  33 
Prune-water,  149 
Pruriginous  inflammations,  304 
Pyloric  obstruction,  313 
artificial  feeding  in,  344 
charcoal  test  for,  323,  331 
complete  obstruction,  316 
complications  in,  334 
diagnosis  of,  331 
differential  table,  338 
dilated  stomach  in,  321,  329 


380 


INDEX. 


Pyloric  obstruction,   etiology  and 

pathology  of,  314 
gastric  peristalsis  in,  320,  329 
palpable  pylorus,  322,  330 
sodium  citrate  in,  91 
surgical  treatment    (Deaver), 

346 

temperature,  324,  331 
treatment  of,  337 

surgical,  337 

non-surgical,  341 
urine  in,  324,  331 
weight  and   strength   in,  319, 

327 
X-ray  studies  of,  323,  330 

Ramogen,  129 
in  diarrhea,  271 
in  infantile  atrophy,  173 

Rectal  alimentation,  182 

Rice,  146 

Rice-water,  89 

Rickets,  185 

adolesence,  rickets  of,  206 
anterior  fontanelle  in,  198 
blood  and  urine  in,  196,  209 
chest  deformities  in,  199 
compared      with      poliomyelitis, 

207 

complications  in,  213 
craniotabes  in,  192 
detention  in,  195,  208 
diagnosis  of,  210 
digestive  disturbances  in,  194 
enlargment  of  organs  in,  194 
etiology  of,  187 
feeding  in,  214-217 

after  first  year,  217 
headsweating  in,  191 
medicinal  treatment  of,  218 
muscular  weakness  in,  195 
nervous  symptoms  in,  209 
non-medicinal  treatment  of,  220 
pathology  of,  185 
prophylaxis,  214 


Rickets,  pseudorachitic  palsy,  207 

skeletal  changes  in,  200 

stools  in,  194 

symptoms  of,  191 

treatment  of  anemia  in,  220 
Rotch's  method  of  milk  adaptation, 
50 

Salts  of  human  milk,  34 
Scurvy,  222 

appearance  of  mouth  in,  226 
blood  picture  in,  226 
complications,  230 
diagnosis  of,  228 
distinguished  from  rheumatism, 

228 
etiology  and  pathology  of,  222, 

223 

symptoms  of,  223 
treatment  of,  230 
Skimmed  milk,  55,  76,  77 
in  diarrhea,  237 
in  fat  intolerance,  112 
in  infantile  atrophy,  179 
in  vomiting,  271 
Sodium  bicarbonate  in  adaptation 

of  cows'  milk,  91 
Sodium  citrate   for  bovine  curds, 

71 
in   adaptation   of   cows'  milk, 

91 

in  infantile  atrophy,  175 
in  protein  intolerance,  109,  175 
in  pyloric  obstruction,  91,  346 
in  vomiting,  due  to  curds,  238 
Somatose    milk,    composition    of, 

131 

in  diarrhea,  271 
in  infantile  atrophy,  173 
Soup,  burnt  flour,  146 
Sour  milk,  121 
Southworth's  soup,  37,  44 
Soya  bean,  133 

Soxhlet's  Nahrzucker  (see  Dextri- 
Maltose),  138 


INDEX. 


381 


Spasmophilia,  276 

association  of  rickets  with,  280 

carpopedal  spasm,  288 

Chvostek's  sign,  282 

definition  of,  276 

diagnosis  of,  291 

eclampsia,  289 

electrical  reaction,  284 

estimate    of    electrical    reaction 
in,  277,  286 

etiology  of,  276 

excretory  symptoms,  289 

gastric  lavage  in,  295 

irregular  forms  of,  290 

laryngospasmus,  287 

manifestations  of,  277 

predisposing  causes  of,  279 

symptoms     of     latent    spasmo- 

philia,  281 
of  manifest  spasmophilia,  281 

treatment  of,  292,  294 

Trousseau's  phenomenon,  283 
Spinach,  147 

Split  proteins,  120  (see  Whey). 
Spondylotherapy,  259 
Starch    atrophy    (see    Mehlnahr- 
schaden),  152,  160 

in  constipation,  251 
Sterilized  milk,  94 
Stomach  washing  (see  Lavage). 
Stools  in  breast  feeding,  29 

in  diarrhea,  262,  265 

in  exudative  diathesis,  306 

in    fat   indigestion   and   intoler- 
ance, 33,  111 

in  infant  atrophy,  158 

in  protein  indigestion,  33 

in  rickets,  194 

in  scurvy,  224 

in    sugar   intolerance   and   indi- 
gestion. 33,  113 

test  for  fat  in,  111 
Strophulus,  304 

Substitutes  for  malt-sugar,   136 
Sugar,  digestion  of,  72 


Sugar,  excess  of,  in  rickets,  187 
indigestion  of,  33 
intolerance,    buttermilk    in,    73, 

114 

Dextri-Maltose  in,  114 
eiweissmilch  in,  73,  114 
in  diarrhea,  260,  264 
in  rickets,  215 
stools  in,  113 
symptoms  of,  113 
treatment  of,  114 
vomiting  in,  237 
Summer  diarrhea,  sugar  as  cause 

of,  72 

stools  in,  262 
vomiting  in,  240 
Syphilis,  breast  feeding  in,  41 

Tetany  (see  Spasmophilia)  in 
rickets,  209 

Toast-water,  148 

Top-milk  method  of  milk  adapta- 
tion, 50 

Trousseau's  phenomenon,  283 

Urine  in  pyloric  obstruction,  324, 

331 

in  rickets,  196 
in  fat  intolerance,  112 
in  sugar  intolerance,  113 
in  protein  intolerance,  107 

Vomiting,  causes  of,  233,  242 

as  symptom  of  hydrocephalus, 
242 

cyclic,  245,  333 

in  abdominal  disease,  242 

in  breast  feeding,  29,  33 

in  complete  pyloric  obstruction, 
316 

in  diarrhea,  273 

in  fat  intolerance,  111,  236 

in  incomplete  pyloric  obstruc- 
tion, 325 

in  infancy,  232 


382 


INDEX. 


Vomiting  in  infantile  atrophy,  158 
nervous,  239 
in  older  children,  242 
in  postoperative  pyloric  obstruc- 
tion, 340 

in  protein  intolerance,  238 
in  pyloric  obstruction,  238 
in  rickets,  194 
in  summer  diarrhea,  240 
in  sugar  intolerance,  237 
Paraf  Javal  solution  in,  240 
sodium  citrate  in,  238 
treatment  of,  241,  243 


Weaning,  47 

Weight  disturbance,  110 

Wet-nursing,  45 

Wheat-flour  water,  88 

Whey,  55 

in  cream  mixtures,  120 
in  fat  intolerance,  112 
in  infantile  atrophy,  172,  179 
in  protein  intolerance,  107 
in  pyloric  obstruction,  341,  342 
in  vomiting,  241 
preparation  of,  119 
wine,  121 

Zweiback,  149 


Date  Due 


PRINTED    IN    U.S.A.  CAT.      NO.      24       16) 


000416973 


WS120 

L917p 
1916 
Lovrenburg,  Earry. 

Practical  treatise  on  infant 
feeding  and  allied  topics. 


WS120 
L917p 

1916 

Harry. 

Practical  treatise  on  infant  feeding 
ind  allied  topics. 


« 

i. 


* 

o. 

g 

00 


MEDICAL  SCIENCES  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 

IRVINE,  CALIFORNIA  92664 


